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HOSPITAL 
TRAINING-SCHOOL METHODS 


AND 


THE HEAD NURSE 


BY 


CHARLOTTE A. AIKENS 


Late Director of Sibley Memorial Hospital, Washington, D. C.; late Super- 
intendent of Iowa Methodist Hospital, Des Moines, and of Columbia 
Hospital, Pittsburg ; Associate Editor of the National Hospital Record 


EPs 


PHILADELPHIA AND LONDON 


W. B. SAUNDERS COMPANY 


1907 


Copyright, 1907, by Ww. B. Saunders Co 
) 


Hn te PRESS OF 
i i W. B. SAUNDERS CO! 


Preface 


Onz of the most significant and at the same time hopeful 
words used in discussing present conditions is the word 
“problem.” We hear it everywhere. “Church prob- 
lems,” “industrial problems,” “social problems,” “city 
problems,” “rural problems,’ loom up on every side. 
The word itself is prophetic, for as soon as a condition 
takes definite shape as a problem demanding solution, 
the time of its solution is never very far distant. 

The hospital world has its problems—weighty and per- 
plexing many of them are. Not the least of these is the 
training school. ‘The training school has been for years 
a very perplexing, as well as a highly important, part of 
hospital work. Considering the fact that every year, 
boards of managers with but very imperfect conceptions 
of their responsibilities have been busy launching and 
“managing”’ training schools, and that nurses and phy- 
sicians with just as imperfect conceptions of the qualifica- 
tions and requirements for teaching have assumed the 
responsibilities of instructors in these training’ schools, 
it is not strange that the training school problem has arisen. 
Confusing and difficult as it is, at present, the condition 
would be still more unfortunate and discouraging if it 
were not regarded as a problem; if this present chaotic 
condition did not perplex and disturb. 

In the beginning of the era of trained nursing in 


America, we were satisfied with a rudimentary training. 
3 


aS 


PRE PAYG E 


Little by little this has been added to, until at the present 
time, a hospital which admits a pupil to its training depart- 
ment is expected to start her in at the kindergarten stage 
in nursing, and conduct her by a swift high-pressure sys- 
tem, clear through the university stage all in the short 
space of two or three years. 

This handbook is an attempt to discuss some phases 
of the training school problem; to suggest to workers in 
that field, plans that have been tested; to give definite 
help to those who are beginning the work of teaching and 
supervising in hospitals. It has been undertaken because 
of a sincere conviction that such a book was needed. 
Good text-books dealing with ‘nursing, the real practical 
bedside care of the sick, are plentiful, but on the subject 
of methods of teaching and supervising, our stock of 
literature is woefully scant, if, indeed, there is anything 
on the subject available. 

Experience and observation have shown that many 
capable graduate nurses who assume the responsibilities 
of teachers and head nurses have but a very vague idea 
as to their relation to the institution, its officers, patients, 
physicians, pupil nurses, and other head nurses. They 
have but faint conceptions as to their opportunities or 
the scope of their influence. ‘They have given but little 
thought or study to the question of how to teach. The 
suggestions contained in this little volume will probably 
not all be applicable to any one institution, head nurse or 
teacher, but it is expected that some suggestions will be 
found useful to all. They are the outcome of no little 
experience in observing, supervising and teaching nurses. 
The matter has been “in the loom” for a number of years, 
and the author sincerely regrets that because of lapse of 


Pn Ey Ae E 5 


time and the distractions of hospital life, it is impossible 
to name all the sources from which inspiration and practical 
points have been obtained. To the members of The 
American Hospital Association and the American Society 
of Superintendents of Training Schools, whose writings 
have furnished valuable suggestions, her obligation is great. 

Some of the papers on “The Head Nurse” have ap- 
peared in the columns of “The Canadian Nurse” maga- 
zine, and some sections of the papers on teaching in the 
“National Hospital Record.” The author takes this oppor- 
tunity to thank the readers of those journals in the United 
States, Canada, and England who have taken pains to 
write and personally express appreciation of her attempts 
to pass on the knowledge gained by experience and special 
study. ‘The very general and cordial welcome accorded 
to the papers that have been presented on the subject in 
those journals has seemed to justify the effort to revise, 
add to, and put them into permanent form. The greater 
part of the book is now given to the public for the first time. 

The criticism of the Irish literary reviewer, that “There 
was so much omitted that should have been in the book,” 
doubtless applies to this little handbook. It is in no sense 
intended to be exhaustive. As a pioneer in its special 
field, it doubtless is defective in many particulars. It is 
believed, however, that it may be useful in directing more 
attention to the questions of how to teach, what should 
be taught, and the responsibility of head nurses and super- 
visors. It is hoped that it may afford practical help, not 
only to the nurse who is beginning to teach, but to all who are 
in any way dealing with the problems of the training school. 


CuarRLoTTeE A. AIKENS 
Detroit, November, 1907 


Contents 


HOSPITAL TRAINING-SCHOOL METHODS 


@aArrEr [—THr PROBLEM STATED. .---..--------------+------ 
Introduction—Essentials of Nursing—Hospital Responsibili- 
ties. 

CHAPTER II.—PLANNING THE COURSE OF STUDY...-.------------ 
Length of Training Period—Arrangement of Studies—What 
Should be Taught.—Special Lectures—Outline of Course of 
Study—Elective and Post-graduate Courses. 


CLAP RI INU ben APIS eae oe oe cose sniee see aero Se 
Character of Pupils—Educational Requirements—Training 
School Responsibilities—Future Policy. 


CHAPTER IV.— PRELIMINARY TRAINING. .----------------------- 
Importance of Preliminary Instruction—Impractical Methods 
—Management of the Preliminary Course—Results. 


CHAPTER V.—THE ArT OF TEACHING...-.-.------------------- 
Methods of Instruction—Essentials of Teaching—Securing the 
Pupil’s Coéperation—The Recitation—The Art of Question- 
ing—The Review—The Examination—The Lecture System 
Versus Recitations. 


CusprnRAVll——WXAMINATIONDS. fc soi neicte snes cele seieiele a eeiee 
Practical and Theoretical Tests—Elements of a Good Answer— 
General Rules for Conducting Examinations—Preparation of 
Papers. 


CHAPTER VII. FUNDAMENTAL PRINCIPLES...------------------ 
Need of Thoroughness and Simplicity—A Few General Princi- 
ples—Fundamental Principles of Materia Medica and Thera- 
peutics—Fundamental Principles in Dietetics. 


CraAprer VITI——PeAceinG DIETETICS: <2. 5. 52202-see52552% e2e= 
How Much Should a Nurse Know—First Year Studies—Second 
Year Studies—Management of the Course. 

CHAPTER IX.—TEACHING ANATOMY AND PHYSIOLOGY..-.--.------- 
How Much Should be Taught—Planning the Studies—Non- 
SS Sane ing Should Teach—Theories and How They 

orked. 


7 


31 


36 


41 


51 


57 


80 


go 


8 CONTENTS 


CHAPTER X.—TEACHING PRACTICAL NURSING.....-.------------ 
Importance of Teaching Correct Methods—Clinical Demon- 
strations—Bed-making—Sanitary Methods—Care of Rooms— 
Enemata—Administration of Medicines—Baths. 


CHAPTER XI.—TEACHING HOW TO OBSERVE SYMPTOMS.....-..--- 
Importance of Habits of Observation—Methods of Teaching— 
Outline of Clinical Course in Observation. 


CHAPTER XII.—TEACHING MATERIA MEDICA........-.-.------- 
How to Teach Materia Medica—Who should Teach—How 
much should be Taught—Some Things not in Text-books. 


CHAPTER XIII.—TEACHING BACTERIOLOGY AND SURGICAL TECHNIC 
How much Bacteriology Should be Taught—How not to Teach 
—Laboratory Demonstrations—Methods of Teaching Surgical 
Technic. 


CHAPTER XTV.— TEACHING OBSRETRICS. 2222-550 - ee eee 
Need of Thoroughness—Conditions in Some Modern Hospitals 
—Clinical Demonstrations. 


CHAPTER XV.—TEACHING GYNECOLOGY.......----------------- 
How much Should be Taught—Points to Emphasize—Practi- 
cal Methods. 


CHAPTER XVI.—TEACHING PRIVATE NURSING AND VISITING NURS- 


Requirements for Private Nursing—Reasons for Failure— 
Methods of Teaching—Ethics of Private Nursing—Visiting 
Nursing—Qualifications. 


CHAPTER XVII.—SPECIMEN EXAMINATION PAPERS....-...------- 


THE HEAD NURSE 


CHaAprEr XVIIT.—Tar HEAD NURSE... 2. --5--- 2. eee eee 
Qualifications—Relations to Hospital, Physicians, Pupil 
Nurses, other Head Nurses—Some Practical Difficulties. 


CHAPTER XIX.—THE HEAD NURSE AND HER PATIENTS..-..-.---- 
Reception of New Patients—Points to Guard Against—The 
Patient’s Friends—Incompatibilities—Religious Beliefs. 


CHAPTER XX.—HospPITAL ETHICS AND DISCIPLINE..------------- 
Head Nurse’s Relation to Rules—Need of Fairness with Pro- 
bationers—First Principles in Teaching Ethics—Honesty— 
Obedience—Personality—Social Relations—Violations of Rules 
—Methods of Maintaining Discipline—Personal Responsibility 
—Discreetness of Speech—Carriage—Quietness—Expression 
of Appreciatiohn—Habits of Criticism. 


116 


126 


137 


144 


149 


155 


164 


186 


194 


CONTENES 9 


PAGE 
CHAPTER XXI.—WAaARD HOUSEKEEPING AND GENERAL MANAGE- 


General Principles—Orders—Daily Inspections—Management 
of Meals—Preparing the Diet Sheets—Common Failings— 
System—A buse of Hospital Supplies—Responsibility Regarding 
Drugs—Monthly Reports—Weekly Records. 


CHAPTER XXL —ORDERS AND REPORTS: 22207 qos sesce oe cose = 224 
System of Writing Orders—Teaching Nurses how to Record 
—Points to Emphasize—Weak Points. 


CHAPTER XXIII.—THE NIGHT SUPERVISOR.....-..-..---------- 234 
Relation of Night Supervisor to Physicians and Other Head 
Nurses—Planning Work for Pupils—Difficulties—Discipline 
Among Night Nurses—Personal Influence. 


CHAPTER XXIV.—THE CHIEF SURGICAL NURSE.....------------ 242 
Organizing the Operating-room Work—Economy—Manage- 
ment of Linen—Weak Points—Opportunities of Teaching. 


CHAPTER XXV.—THE HEAD NURSE AND CASE HISTORIES.......-. 253 
Facts to be Secured—Family History—Present Conditions— 
Operating-room Histories—Obstetric Histories. 


Hospital Training-school 
Methods: and the Head Nurse 


——es 


CHAPTER I 
The Problem Stated 


Nursing, in the modern acceptance of the term, is both 
a science and an art. Its real essence is and must always 
be personal service-to the sick or helpless. ‘The study of 
the science is valuable in direct proportion to the extent 
to which it helps the student to practise the art, and render 
that service intelligently and efficiently. ‘The real care of 
the sick must always be the first consideration. All other 
aspects of nursing are, and must continue to be, secondary 
in importance. The ideal training is, therefore, not that 
which covers the most ground, but that which fits a nurse 
to render the highest and best practical service to the sick. 

Essentials of nursing are the things which concern all 
nurses: the skill and knowledge which every trained nurse 
who has a right to the name needs, whether her service is 
rendered in city or country, in home or hospital or camp, 
whether as an executive or an independent or obscure 
worker. Beyond the circle in which is included the essen- 
tials of nursing there stretch in all directions wide and 
alluring fields of knowledge. In attempting to teach the 


essentials, little by-paths have been started leading into 
11 


12 THE PROBLEM 8 Tiga 


these broad and attractive fields. To wander off and get 
confused ideas regarding essentials is as easy as to get con- 
fused in a strange city where a number of roads meet. 
These by-paths, many of them, lead to specialties to which 
nurses may legitimately aspire after a certain experience 
has been gained. No human being, nor organization, 
has a right to say to another human being, or class, “Thus 
far shalt thou go in the pursuit of knowledge but no far- 
ther.” That right belongs to no one. Every nurse, in 
common with every other individual, has a right to develop 
her God-given talents as she chooses and finds opportunity. 

There is no real reason why the hospital pharmacists 
of the future should not be nurses who, having mastered 
the essentials of nursing and graduated as nurses, have 
followed up the elementary knowledge of drugs obtained 
by a full course in pharmacy. ‘There would be decided 
advantages in having the dietetic department of a hospital 
in charge of a nurse who had specialized in the branch of 
dietetics. If the matrons or hospital housekeepers were 
nurses who had, in addition to a nursing education, ac- 
quired a thorough knowledge of household science, there 
would be still further advantages. No one is able to say 
that progressive physicians in the future will not choose 
nurses as assistants in pathologic laboratories; that they 
will not find nurses who choose that line of work and are 
adapted to it more valuable in such work as making blood- 
counts, analyzing specimens, etc., than many of the in- 
ternes who now perform such service. Nurses have been 
trained by leading surgeons to assist as anesthetists. 
Nurses have become expert surgical assistants. ‘Thus, 
these illustrations might be multiplied regarding special 
lines of work connected with the care of the sick, in which 


rei eOBLEM STAT ED 13 


nurses may possibly engage. What new work will be de- 
manded of or intrusted to the nurses of the future no one 
can foretell. 

In the teaching and training of nurses the greatest diffi- 
culty has arisen from the confusion of ideas that exists 
regarding the essentials, the things which it is necessary 
that all nurses should know, and which hospitals are re- 
sponsible for teaching. Clearly, a school which announces 
that it will provide an all-round training for nurses is re- 
sponsible for teaching the essentials. It ought not to be a 
difficult matter for hospital organizations to agree as to 
what these real essentials are. In business circles there is a 
broad and thoroughly understood policy and coéperation 
that is in itself a source of strength, relief, and security. 
There is no reason why hospitals should not reap the 
same benefit from codperation, at least as regards the 
teaching and essentials of nursing. There is no real reason 
why they may not come to an agreement as to what these 
essentials are, if they will seriously and impartially consider 
the matter from its foundations, and in its entirety, and 
work together with a determination to find a solution of 
the problem and accept it. 

Inasmuch as the primary business of hospitals is really 
to care for the sick, it does not seem reasonable that hos- 
pital training-schools which undertake to teach nursing 
from the very foundations should be expected to do more 
than teach the essentials of nursing. It does seem reason- 
able that schools which claim to give postgraduate training 
should be expected to go beyond the essentials. A nurse 
who reénters a hospital for postgraduate training has a 
right to expect a systematic advanced course of study in 
some direction. 


14 THE PROBLEM Stas 


The problem that underlies all other phases of nurse 
training and progress is, then, the problem of the essen- 
tials. What are the essentials of nursing? Centering 
around this problem are numerous others that rightly 
claim attention. How shall these essentials be taught? 
Who shall teach? Whom shall we admit to be taught? 
Whom shall we exclude? How long should a nurse be 
required to spend in acquiring a working knowledge of 
the essentials of nursing? ‘These and many other ques- 
tions are pressing for solution. Out of all this chaos and 
confusion of tongues must inevitably come a clearer vision 
of the question, Where does the hospital’s responsibility 
to a candidate whom it admits for training begin and end ? 


CHAPTER II 


Planning the Course of Study 


At the present time considerable diversity of opinion 
exists as to the length of time required to teach nursing 
properly. The three-year term was adopted by leading 
hospitals years ago, when there was a great deal of nursing 
material from which to make selection of candidates. All 
over the country, hospitals, small and large, followed the 
example of the larger hospitals in adopting three years as 
the limit of the training period. It was found to be a dis- 
tinct advantage to the institution to retain nurses for an- 
other year, and, of course, more time was available in 
which to teach. Nurses could pursue their studies more 
leisurely and went out at graduation with an added year 
of experience, which is always valuable. In many hos- 
pitals more thorough teaching was done under the three- 
year régime, but in many this desirable effect from a 
lengthened term has not been realized. With more time, 
more studies have been added year after year, many of 
them of very little, if any, practical value in a nurse’s 
course. ‘There is a growing number of intelligent people 
in different parts of the country who believe that it is still 
possible to teach nursing, and teach it properly, in two 
years. As previously stated, there can be no possible 
objection to a nurse following up any subject in which she 
may have a special interest. If she wants to add to nursing 
medicine, and to medicine pharmacy, and to pharmacy 

15 


16 COURSE OF S Pita 


sociology, psychology, or biology, there will not be lacking 
people who will bid her God-speed in her pursuit of knowl- 
edge. “Hitch your wagon to a star” is very good advice 
to any student, but if a hospital training-school teaches 
nursing, and teaches it thoroughly, and teaches real hos- 
pital work and methods besides, it will have done its share 
toward equipping nurses for their life-work. 

The three-year course of study outlined here was ar- 
ranged after a consideration of the curricula prescribed 
in more than a score of training-schools whose standing 
is unquestioned. In it the aim has been to include such 
instruction as would be of real practical use to the nurse 
in dealing with disease, and to eliminate, as far as possible, 
superfluities and non-essentials. When one considers the 
small amount of time that can really be given to theoretic 
study in any school of nursing; the adverse conditions 
under which the nurse has in most instances to pursue 
her studies; the bodily fatigue and mental anxiety that 
cannot be avoided in a nurse’s life, the question of how 
to lessen the burdens of the nurse becomes highly impor- 
tant. How to give her an education that will make her 
an efficient worker, an intelligent ally of the physician, 
and yet avoid loading her down with “mint and anise and 
cummin,” to the neglect, often, of the “weightier matters,” 
and of thorough teaching of correct practical methods, is 
one that demands serious consideration. 

If, in the latter half of the course, she could be given the 
same chance that is given to medical students in some of 
the best colleges, to if not exactly specialize, at least to 
become more familiar with the line of work she wants to 
follow after graduation, it would be an immense improve- 
ment over the system now prevailing in certain hospitals. 


COURS EF OF STUDY 17 


No hospital can convince the public in this age that it is 
really giving justice to its nurses if it keeps them for a three- 
year training and neglects to make arrangements for an 
all-round course. It is certainly unjust for any hospital 
that claims to give a general training to neglect to make 
provision for its nurses to acquire midwifery experience; 
and the time will come when no general training will be 
considered complete if practical experience in nursing the 
insane has not been a part of the training. A system of 
affiliation between hospitals, whereby experience in one 
will be made to supplement what is lacking in the other, 
is possible in very many places. If a plan of interchange 
could be arranged between hospitals for the insane and 
general hospitals, whereby the nurses in both classes of 
institutions could gain a wider experience, it would be a 
decided advantage. 

The nurse who has had no practical experience and 
training in dealing with nervous, hysteric, or insane pa- 
tients is as unfitted to care for such cases efficiently as the 
nurse who has dealt only with such cases is to undertake 
to care for a typhoid-fever or pneumonia patient efficiently. 
The body is not a mass of disorganized units or parts, and 
if a nurse is to undertake to care for the whole human 
machine, she needs the experience with the diseases that 
afflict the whole machine. If the hospital claims to give 
a general training, it should make provision for a general 
experience. 

Since the great majority of pupils enter the ranks of 
private nurses after graduation, a well-balanced curriculum 
would certainly provide for some special instruction and 
training in this branch. 


Visiting nursing is another line of work that is develop- 
2 


18 COURSE OF STUB 


ing, if not rapidly, at least steadily, and many hospitals 
now include training in visiting nursing in their course. 

The very great need for competent male nurses, both in 
the hospital and in private nursing, coupled with the abso- 
lute inefficiency of the average hospital orderly, on whom 
we have been accustomed to depend for assistance in 
the care of male patients, has induced certain hospitals 
to undertake the training of male nurses, with very great 
advantage to the institution, besides affording opportunity 
for the young man to enter a remunerative occupation with 
little outlay of capital. Inasmuch as the young man’s 
field is more limited as a nurse than that of the young 
woman; considering that he will hardly be called on to 
assume charge of a hospital, to become a head nurse, an 
operating-room nurse, to nurse children, or obstetric or 
gynecologic cases, it certainly seems desirable to arrange 
so that he will complete his course in two years. It is also 
highly desirable that he, especially, be given opportunity 
to acquire some experience and training in the care of the 
insane. 

The nurse’s life while in the hospital is likely to be de- 
pressing and to leave her with very narrow views of life 
unless some effort is made to combat the influences that 
lead to this condition. With a view to broadening her 
outlook on human life in general, and increasing her sym- 
pathy with infirm and unfortunate humanity, some of the 
best training-schools have arranged a special course of 
lectures dealing with charity, philanthropy, and other sub- 
jects. Quite frequently, at such times, current events and 
social questions are discussed. Experts in other lines of 
human endeavor bring of their knowledge and experience 
and afford glimpses of what is going on in the great world 
outside hospital walls. 


CavuRs © OF § FU DD ¥ 19 


Quite a number of hospitals carry on, throughout the 
greater part of the year, regular weekly Bible classes, and 
the custom is certainly one to be commended. If we 
expect nurses in their daily life to exhibit the Christian 
graces, to be honest, kind, charitable, to refrain from harsh 
judgments, to be just and true, to keep “‘sweet” whatever 
happens, it is worth while to take a half-hour occasionally 
to think on these things, to study how these virtues may 
be cultivated. ‘These special lectures and classes are not, 
as a Tule, compulsory. No dreaded examination will 
follow them, but they are distinctly helpful to the nurse, 
and through her, to the hospital. 

The list of topics appended may afford suggestions in 
arranging for such a course: 

1. The industrial situation in the twentieth century. 

2. Defective, dependent, and delinquent members of 
the human family—our responsibility concerning them. 

3. Municipal and State charities and their functions. 

4, The twentieth century city and its charitable insti-‘ 
tutions. 

5. Needy families in their homes—effective help and 
adequate relief. 

6. Nursing legislation. 

7. Where law and nursing and hospitals meet. 

8. Present-day opportunities and responsibilities of 
the nurse. 

9. The church as a factor in social progress. 

10. Some significant world movements. 

11. The English Bible—how to study and use it. 

12. Child-saving institutions. 


ad 


20 COURS EvO¥F Si? Uae 


i 
THe CurRICULUM 


This course of study in the principles of nursing and 
allied subjects is divided into four periods—preparatory 
period, junior, intermediate, and senior years. Pupils 
will not be allowed rank in classes of higher grade until 
the required work in preceding classes has been completed. 


PREPARATORY PERIOD 


The preparatory course extends through the probation 
term and includes— 


TEN LESSONS IN PRINCIPLES OF NURSING 

1. Care of the hospital ward: routine of work, cleanli- 
ness, order, economy, sweeping, dusting, ventilation, hy- 
giene of the ward, reception of patients. 

2. Bed-making; bed-sores; general care of bed-patients; 
ward management. 

3. Temperature: use and care of clinical thermometers; 
pulse and respiration. 

~ 4. Observation of symptoms; bedside records. 

5. Medicines: general care and precaution, methods of 
administration; medicine closets; abbreviations and sym- 
bols; tables of weights and measures. 

J 6. Baths and their uses; function of the skin; hot and 
cold packs. 

7. The intestinal tract: enemata—purposes, mode of 
administration, care of appliances; suppositories; urine in 
health and disease; use and care of catheters; rules regard- 
ing specimens for examination. 

8. Local applications: counterirritants, poultices; mode 
of applying heat and cold. 


COURSE OF STUDY 21 


9. Methods of examination; preparation for examina- 
tion; care of patients after operation. 
10. Contagion and disinfection. 


FIFTEEN LESSONS IN COOKING AND PRINCIPLES OF NUTRITION 

Chemic composition of the body and of food. Sources. 
Classification. Uses in diet of water, protein, carbohy- 
drates, fats, and salts. Lists of foods for tissue-building 
and production of heat and force. Composition of some 
typical foods. Uses and preparation of fluid foods and 
beverages. (I'wo demonstrations.) 

Food value and preparation of semisolid or liquid and 
farinaceous foods. 

Nutritive value of albuminous foods. Cooking of eggs 
with and without other foods. 

Study of flesh foods. Cooking of meat and fish. (Two 
demonstrations.) 

Broths, meat and vegetable soups, purées, etc. 

Foods supplying acids and salts. Vegetables. Prepara- 
tion and serving. (Two demonstrations.) 

Bread, toast, sandwiches. Methods of preparation and 
serving. 

Desserts and fruits. (Two demonstrations.) 

Salads: chicken, fish, fruit, beans, lettuce, ete. 

Miscellaneous dishes: dressings, sauces, croquettes of 
rice, etc., wafers. How to make food attractive. 


TEN LESSONS IN BEDSIDE METHODS BY PRACTICAL “alt 


DEMONSTRATION 
1. Beds, bedding, bed-making, with and without pa- 
tient, management of helpless patients, changing beds, 
bed-making for operative patients, rubber cushions, bed- 


22 COURSE OF STUD 


rests, cradles, arrangement of pillows, ete.; substitutes for 
hospital appliances. 

2. Sweeping, dusting, preparing room for patient; dis- 
infection of bedding, furniture, etc.; care of patient’s cloth- 
ing in ward and private rooms. 

3. Care of linen rooms, care of bath-rooms and appli- 
ances; disinfection of excreta. 

4. Baths: full, sponge, to reduce temperature, foot- 
baths, hot-air. 

5. Administration of rectal injections for laxative, 
nutritive, stimulant, astringent purposes; care of appli- 
ances. 

6. Vaginal douches; methods of sterilizing appliances; 
use and care of catheters. 

7. Hot and cold applications; care of hot-water bottles; 
uses and care of ice-caps and coils. 

8. Chart-keeping; methods of recording bedside obser- 
vations. 

9. Making of bandages—roller, many-tailed, plaster, 
abdominal, breast; some methods of applying bandages. 

10. Appliances to prepare for ward examinations and 
dressings. Sterilization. Nurse’s duties during ward 
dressings. Preparation and care of surgical dressings; 
sponges, swabs, ete. ~- 


TEN LESSONS IN THERAPEUTICS AND MATERIA MEDICA 

1. Introduction.—Remedial agents in general: heat, 
cold, light, air, electricity, rest-cure, water, serums, trans- 
fusion, medical gymnastics, mechanotherapy. Brief de- 
scription of the uses of these as remedial agents. 

2. Materia Medica.—Appearance of crude drugs. 


COURS by OF 5S fa DY 23 


Sources and derivatives. Definitions of pharmaceutic 
terms. Pharmaceutic preparations. 

3. Classification of Drugs.—Common illustrations of 
each class. Elimination of drugs. 

4, Weights and Measures.—Apothecaries’ weights, 
fluid measures, approximate measures, graduated glasses 
and their uses. 

5. The French or Metric System.—Approximate values 
of old and new system. Dosage. Plan of dosage of veg- 
etable drugs. 

6. Cardiac Stimulants and Sedatives.—Principal drugs 
used and physiologic action. 

7. Cathartics.—Drugs in common use, laxatives, simple 
purgatives, drastic purgatives, intestinal astringents. 

8. Tonics.—Digestants, stomachics. 

9. Nerve Sedatives.—Anodynes, hypnotics. 

10. General Lecture.—Diuretics and diaphoretics; anti- 
septics and disinfectants; precautions in handling drugs; 
practical demonstration in preparation of seidlitz powder, 
carron oil, lotions, ointments, toilet powders, mouth- 
washes, ete. 


—_ 
FOUR LESSONS IN BACTERIOLOGY 


1. Brief history and general theory of bacteria; bacteria 
in natural processes. 

2. Description of most important bacteria; mode of 
multiplication. 

3. Common communicable diseases; how infection is 
conveyed; immunity—natural, artificial, acquired. 

4. Principles of sterilization and disinfection; principles 
on which aseptic surgery is based; channels by which 
organisms may reach wounds; hand disinfection, 


24 COURSE OF ST tp 


NINE LESSONS IN ANATOMY AND PHYSIOLOGY 

1. Chemistry of Body.—General structure; the systems 
of the body. 

2. The Skeleton.—Composition of bone; ligaments; 
cartilage; joints. 

+ 3. The Muscular System.—Arrangement and structure. 

The levers of the body. 

4. The Organs of the Thorax and Abdomen.—Their 
relative position and functions. 

5. Waste and Repair.—The origin of tissue; the cell. 

6. The Excretory System. 

7. The Digestive System.—Absorption. 

8. The Nervous System. 

9. The Blood.—Its composition and functions; the cir- 
culatory system. 

The study of anatomy and physiology will be continued 
at intervals throughout the entire course, the anatomy and 
physiology of special organs being studied in connection 
with the lectures on diseases of those organs. 


LESSONS IN ETHICS 
The superintendent will conduct classes and give instruc- 
tion in ethics at frequent intervals throughout the whole 
course. 


THREE LESSONS IN THE PREPARATION OF SOLUTIONS 
1. Definitions.—Disinfectants, antiseptics, germicides, 
deodorants, containers, labels, most common disinfectant 
solutions, saturated solutions. How to ascertain quantities 
of drug in solutions of various strengths. Conditions that 
modify action of disinfectants. Corrosive sublimate: when 


COURSE OF SPODY 25 


to use and when not to use; general strength for hand dis- 
infection; effects on tissue. Boric-acid solution. 

2. Carbolic-acid solution: how to prepare; effects on tis- 
sue; precautions; neutralization. 

3. Potassium permanganate, oxalic acid, lysol, creolin, 
alcohol, formalin, Thiersch’s solution, chlorid of lime—gen- 
eral characteristics and effects, how to prepare. 


FIVE LESSONS IN HOUSEHOLD ECONOMY = 

1. House rules: relation to servants, care of rooms, fur- 
nishings, etc. 

2. Marking personal and hospital clothing, prepara- 
tions for laundry, amounts allowed, care of hospital linen, 
mending and making, disposal of worn linen. 

3. Care of refrigerators, diet-kitchens, cupboards, stoves, 
dish towels, and utensils. 

4, 'Tray-setting and serving of food, removal of trays 
and dishes, disposal of fragments. 

5. The hospital diet sheets: classes of diets; amounts, 
care, and preservation of food; economy; cleanliness; spec- 
imen menus; special diets. 


JUNIOR YEAR 


Theory of Nursing, continued. 

Materia Medica, continued. 

Hygiene, general and personal. 

Preparation of Patients for Operation—postoperative 
care. 

Bandaging, principles and practice. 

Hydrotherapy.—General principles and treatment; phy- 
siologic effects of heat and cold. External uses of water: 


26 COURSE OF STUD 


compresses; tepid, warm, hot, shower, medicated, bran, 
mercurial, sulphur, salt, soap, and Schott baths; Scotch 
douche, spinal sprays, etc. Internal uses of water: lavage, 
irrigations, enteroclysis, saline injections, hypodermoclysis, 
intravenous infusion. 

The Urine.—The urinary organs. Symptoms of disease. 
Urinalysis. Common tests by practical demonstration. 

Symptomatology.—Methods of observation, general and 
special. 


INTERMEDIATE YEAR 


Obstetrics.—History; anatomy of pelvis; generative or- 
gans; functions and relative position; symptoms, hygiene, 
and pathology of pregnancy; management of normal labor; 
accidents of pregnancy and labor; nurse’s duties during 
labor; puerperal care. 

Pathology of the Puerperium.—Obstetrie operations; 
physiology and pathology of the new-born; premature in- 
fants and their care; infant feeding; obstetric nursing in 
hospitals, in visiting, in private homes; advice to give pros- 
pective mothers. 

Massage as a therapeutic agent: details of treatment, 
contraindications, the various movements, practical dem- 
onstrations. 

Dietetics.—Studies in foods, diet in different diseases, 
dietetic errors and some of their results, food containing 
ptomains, ptomain-poisoning. 

Diseases of the Digestive Organs.—General symptoms; 
indigestion, general management of different forms of dys- 
pepsia, acute gastritis, dilatation of the stomach, gastric 
ulcers, intestinal fermentation, autointoxication, chronic 
constipation, diarrhea, hemorrhoids, appendicitis, 


COURSE OF STUDY 27 


Nursing in Infantile and Children’s Diseases.—The 
normal infant, marasmus, catarrhal jaundice, constipation, 
thrush, cholera infantum, diarrhea, worms, whooping- 
cough, laryngitis, scrofula, rickets; hydrotherapy and 
massage in diseases of children. 

Fevers.—Typhoid fever: seat of disease, symptoms, 
general care of all cases, condition of bowels, hemorrhage, 
perforation, tympanites, reinfection, diet, disposal of ex- 
creta, general precautions to prevent infection, complica- 
tions, management of convalescence. Malarial fever. 
Rheumatic fever. Yellow fever. 

Common Communicable Diseases.—Diphtheria, scarlet 
fever, measles, chicken-pox, small-pox. ; 

Surgery and Surgical Nursing.—Operating-room tech- 
nic; nurse’s duties in operating-room; surgical instruments 
and appliances and their care; operations in private homes; 
wounds and their complications. 

Gynecology.—Common diseases and conditions; gyne- 
cologic operations; nurse’s duties; general management 
of cases. 


SENIOR YEAR 

Accidents and Emergencies.—Medical and surgical. 

Alcohol.—Its use in various diseases; toxicology. 

Nursing in Orthopedic Diseases.—Hip-joint disease, 
Pott’s disease, lateral curvature of the spine, paralysis and 
imperfect development; management of flat foot; how to 

assist the orthopedic surgeon; orthopedic gymnastics. 
_ Diseases of the Kidneys and Urinary System.—Com- 
plications and management. 

Nursing in Diseases of the Heart and Circulatory 
System. 


28 COURSE OF sit Ue 


Nursing in Mental and Nervous Diseases.—Chorea, 
neurasthenia (hysteria, epilepsy, insanity). 

Nursing in Diseases of the Skin.—Modern methods of 
treatment. 

Diseases of the Eye—Ophthalmic nursing. 

Diseases of the Ear, Nose, and Throat.—Intubation, 
tracheotomy, postoperative care. 

Diseases of the Respiratory Organs.—Special lecture 
on tuberculosis—causes, preventive and curative measures, 
general management; the world’s war against tuberculosis. 

General Diseases and Their Management. 

Electrotherapeutics. 7 Theme eae ; light-therapy ; 
therapeutic gymnastics. 

Private Nursing. 

Hospital Economics.—In the senior year nurses will be 
expected to serve as head nurses and in other positions of 
special responsibility. Some special lectures will be given 
on the duties of head nurses, training-school administration, 
division of work, institutional bookkeeping, purchase of 
supplies, hospital government. 

Text-books.—“‘ Human Physiology,” Furneaux. “'Text- 
book of Nursing,” Weeks or Robb, or “ Practical Points in 
Nursing,” Stoney. ‘“‘Hand-book of Materia Medica,” 
Groff, or “Materia Medica for Nurses,” Stoney. “Ob- 
stetrics for Nurses,” De Lee. “Nursing in the Acute In- 
fectious Fevers,” Paul. Medical Dictionary, Dorland or 
Gould. “The Surgical Assistant,” Brickner. “Bac- 
teriology in a Nutshell,” Reid, or “Bacteriology and 
Surgical Technic,” Stoney. “Dietetics,” Friedenwald 
and Ruhrah; and Pattee. ‘‘A Nurse’s Hand-book of 
Medicine,” Henry. 


Cow RSE OF 5S FTUDY 29 


ELECTIVE AND POSTGRADUATE COURSES 


With a little readjustment of this curriculum, by careful 
planning and condensing of the subject matter of the theory 
of nursing and allied subjects, and by avoiding excursions 
into purely medical fields, the third year might easily be 
made elective. A two-year term, exclusive of the probation 
period, seems practical. Most of the lecture courses speci- 
fied for the last year are short. If well arranged, these 
subjects could be covered in from fifteen to eighteen classes 
or thereabouts, which, if divided between two years, would 
not greatly increase the burden, providing the nurse had 
been given opportunity in the probation period to devote 
special time to foundation studies. Where a three-year 
term is required, if, in the third year, the emphasis could 
be placed on preparation for positions of responsibility 
in hospitals, it would be a long step forward. 'There is 
a felt need for all hospitals to give more attention to this 
point, and for some schools, in different parts of the country, 
postgraduate or otherwise, to arrange a course in hospital 
administration of which a nurse can avail herself if she 
contemplates becoming a head nurse or superintendent. 
A series of lectures on the duties of head nurses, their rela- 
tion to the institution, its officers, physicians, patients, 
nurses, and to each other; the organization of ward work; 
the duties of orderlies, wardmaids, nurses; night super- 
vision; operating-room supervision; duty hours for nurses; 
recreation hours; reports, histories; management of diet 
service; cleaning, ete.—such a series would make a course 
that would certainly prove very valuable to nurses and to 
the hospitals in which they might later be called to serve. 

The course on hospital administration in its wider sense 


30 COURSE OF STUDS 


should include: Methods of organization; the funetions 
of the officers and committees of the governing body; the 
organization of the medical staff; its relation to the insti- 
tution; the superintendent’s duties and responsibilities; 
organization of internal working force; rules, regulations, 
and by-laws necessary; hospital accounting; books that 
should be kept in every hospital; counting the cost; statis- 
tics; purchase of drugs and surgical supplies; purchase 
of food supplies; hospital equipment; the laundry, cost 
and management; training-school management; superin- 
tendent’s responsibilities, relation to nurses, faculty, other 
officers; acceptance of probationers; the curriculum; plan- 
ning for classes; division of work; teaching methods in 
theory and practice; examinations; training-school records, 
etc. 'To this might be added lectures on new methods, 
advances in medicine, and special features of nursing, as 
might be decided. This course on hospital administration 
could be given in a well-organized hospital as well as or 
better than in any other institution; and there is every 
reason to believe that a school that gave such a course 
would have no dearth of applicants from the graduate 
nursing ranks. Nurses who now hesitate to reénter for 
postgraduate study because of the fact that most postgrad- 
uate courses do not differ essentially from the undergrad- 
uate courses, would many of them eagerly weleome such 
an opportunity. ‘This course should not, however, be con- 
sidered as included in the essentials of a nursing education, 
nor be required of all nurses. 


CHAPTER III 
The Pupils 


The character of the pupils admitted for training will 
determine, to a large extent, the quality of the work done 
and the real spirit of the institution. It is quite as neces- 
sary to secure good material to train as it is to give a prac- 
tical, well-rounded training. No amount of training will 
make a really good, conscientious, reliable nurse, unless 
she is a good woman to start with. ‘To emphasize purely 
scholastic attainments and minimize the character test is 
not likely to result in good either to the hospital or to the 
nursing profession. However desirable it might be to lift 
at once the whole nursing body to the high plane of intel- 
ligence and efficiency attained by the highly educated 
minority, it cannot be done with one or several strokes of 
legislation; it cannot be accomplished in a few years. The 
evolution of the medical profession from the trades of the 
barber and the apothecary has been exceedingly gradual 
and slow. It is yet a long way from complete. However 
desirable it might be to have no candidates in training who 
have not had the advantage of a high-school education, 
it is serious business, under the present conditions that 
exist as regards material for training, to attempt to fix an 
arbitrary educational standard for the admission of candi- 
dates, especially if that standard is likely to result in de- 
creasing the number of applicants. 

The hospital school differs from all other educational 

31 


32 T H.E PU Pass 


institutions in that it has assumed tremendous responsi- 
bilities. It is made responsible for the actual care of the 
sick twenty-four hours in every day, seven days in every 
week, three hundred and sixty-five days in every year. It 
must provide continuous service to the sick, be the patients 
many orfew. ‘To discharge this responsibility it must keep 
up a sufficient working force. If one nurse is called off 
duty for any reason, another must be found somewhere 
immediately to take up the work she has laid down. ‘The 
needs are constant, pressing, and urgent. ‘They cannot 
be disregarded in an attempt to carry out any theory. ‘The 
typhoid-fever patients, the accident cases, the surgical and 
maternity patients that occupy hospital beds are not the- 
ories. If high-school pupils or graduates come and offer 
to care for them, all well and good. Other things being 
equal, they should have the preference, and have had in 
the past, in accepting candidates. No one questions that 
it would be a very good thing if every nurse had had a high- 
school education, or even if she held a college diploma. 
The same is true of people in most other lines of work. 
But if the high-school pupils or college students do not come 
and signify their willingness to help in caring for the sick, 
the patients must be cared for by somebody else. 

In view of the statement of a social worker* who has in- 
vestigated conditions that—“‘It is an indisputable fact that 
about 90 per cent. of the pupils in the public schools leave 
before the high-school stage. Perhaps two-thirds of this 
number fail to complete the grammar grades”; and of 
another statement made by a prominent educator, that 
less than 5 per cent. of the pupils in rural districts get any 
education other than that received in rural schools—in 

* Howard Woolston, “‘Charities and the Commons,” Sept. 1, 1906. eR 


ELE, (PUR BES 33 


view of these facts it is certainly perilous to fix an arbitrary 
educational standard at the present time, or to limit the 
supply from which applications will be considered to less 
than 10 per cent. of the population, unless we are prepared 
to cease to depend on training-schools for routine nursing 
in hospitals. Had the high-school test been made fifteen 
years ago, it would have barred out many of the brightest 
and best nurses who have graduated from our training- 
schools, and the hospital world would have lost some of 
its most capable superintendents. Natural ability, when 
conditions are favorable to development, will overcome 
many defects, and pupils with good natural abilities are 
the kind that are wanted in hospitals and sick-rooms. 
They may not be capable of becoming teachers and super- 
visors of the highest grade without special educational ad- 
vantages, but all nurses are not called to be teachers and 
supervisors. 

An attempt to limit the supply of candidates by a fixed 
scholastic standard will not only embarrass the hospitals, 
but will almost certainly result in an increase in the ranks 
of graduates of spurious schools of nursing. A young 
woman who has determined to become a nurse, if she finds 
herself debarred from entering a hospital by the high- 
school test, will be very likely to try the next best, the 
shorter, way to secure admission to the sick-room. 

With the very limited supply of candidates left to choose 
from after the 90 per cent. who have not had high-school 
training have been ruled out of consideration by legislative 
restrictions, a careful selection of candidates will be im- 
possible. Even a poor nurse ina hospital countsone. She 
is better than nobody in a vacancy. She may not fill a 


place, but she “rattles around in it.” Having admitted 
3 


34 oo AE Pa Peres 


her on the strength of a high-school diploma, unless there 
is a waiting list of candidates she is likely to be retained 
for the sole reason that no one else has offered who can be 
secured to fill her place. Therefore the attempt to elevate 
the body professional by enforcing a fixed scholastic 
standard at this period in our history, before the country 
as a whole, the homes and schools from which our pupils 
must come, are ready to advance, is fairly certain to end 
in failure. 

A short practical reading course might be prescribed 
for candidates who seem desirable to be admitted for train- 
ing. This course could form a basis for examination on 
entrance, and would probably help to weed out the unfit, 
and’ save them wasting time on probation preparatory to 
work for which they apparently were not adapted. A 
large number of the candidates who enter the hospital 
schools have had the matter under consideration for months 
or years before they were free to leave home or abandon 
other occupations to begin the study of nursing. It would 
certainly be a good thing for the candidates, and also for 
the hospitals, if the period of waiting could be used in the 
way that would best prepare them for the calling they have 
chosen. If candidates were required to have read certain 
specified text-books on household bacteriology and hygiene, 
the chemistry of cooking and cleaning, household manage- 
ment, elementary anatomy and physiology, elementary 
lessons on food and diet, they ought to be better fitted 
either to be good housekeepers or to begin the nursing 
course, and habits of study would not be so hard to form. 

Such a plan is impossible until a closer coéperation and 
more complete agreement of hospital organizations regard- 
ing essentials of training are reached. ‘The questions as to 


PE BUF EES 30 


how the supply of desirable candidates may be increased 
and the essential qualifications for admission need to be 
broadly considered in view of the fact that the policy pur- 
sued regarding these matters will affect the hospital at its 
most vital point. 


CHAPTER IV 
Preliminary Training 


The importance of giving some measure of training and 
instruction to probationers before they are allowed to as- 
sume responsibilities for bedside work is now pretty gen- 
erally recognized in the hospital world. How, where, and 
how much of this instruction should be given are points 
on which a considerable diversity of opinion still exists. 
When a general attempt was first made to put the plan in 
operation, the idea of a school entirely independent of hos- 
pitals to which prospective nurse candidates might go to 
receive preliminary training was advocated and tried with 
varying degrees of success or failure. Comparatively few 
candidates cared to spend months of time and considerable 
money in preliminary training while still in doubt as to 
their general qualifications for the work. Inasmuch as the 
fundamental question as to the essentials for a nursing 
education was still undecided, it was but a natural conse- 
quence that extremes of opinion should exist regarding 
what nurses should be taught during this preparatory 
period, and how long should be spent in preparation. 
Some schools modestly started by giving one month of 
preliminary instruction. Others attempted to teach the 
real essentials for the probationer in three months, while 
others required six months. One school taught its pro- 
bationers to polish silver and scrub kitchen tables and 
shelves, and then apparently led them, by swiftly progress- 

36 


Bee bs PM ENAR Yo ERAEN ENG: 37 


ive steps, until they reached the dissecting-room, where they 
were taught to dissect dogs, cats, and other specimens. 
They also were initiated into the practical work of a phar- 
macist. According to the published statement of one who 
had taken the course, “The probationers go to the phar- 
macy, where, under instruction by a graduate pharmacist, 
they prepare the drugs, make tablets, pills, powders, filter 
medicines, ete.” 

Is this really elevating the standards of nursing? May 
we not believe that it is such extremes as these in methods 
that have been reached in training nurses that have helped 
to create the feeling that has been gaining in strength that 
nurses are being “‘overtrained”? Inasmuch as no agree- 
ment as to what constitutes a well-rounded training has 
been reached it is hard to agree as to the point when “ over- 
training” begins; but the wisdom of introducing nurses 
to the dissecting-room, or of teaching them in the proba- 
tionary period to make pills and prepare drugs, is a point 
that may well be questioned. Whether it ever can be of 
any practical value to the average nurse to have dissected 
dogs and cats, what real advantage is likely to follow such 
experience, are other points on which there might be a 
wide difference of opinion. 

In a great many of the best schools an excellent, thor- 
oughly practical, three or four months’ course of prelimi- 
nary training has been given for several years with very 
gratifying results. Methods of practical nursing and such 
theory as they would need to enable them to discharge 
intelligently the duties they would have when they entered 
the wards have been taught—a very great advance on the 
old system under which nurses had to do a great many 
things in a meaningless, mechanic way, without in the least 


38 PRELIMINARY TRAV 


understanding why they were required or what results 
might be expected. 

The methods pursued in different details have, of course, 
to be modified to suit local conditions, but the following 
description of the plans adopted in one school may be sug- 
gestive: The candidates are notified to arrive on the same 
day—all that are likely to be admitted until the next pre- 
paratory term begins. As far as possible each candidate 
is personally interviewed by the superintendent, either be- 
fore entrance or soon after. Her mental measurements, 
attitude, and probable adaptability are gaged. After the 
class has assembled, the superintendent meets them for a 
few preliminary lectures. The aims and objects of the 
institution are put before them. ‘They are told of the re- 
sponsibilities of the work, and of the qualities essential 
for it. The real meaning of nursing, the spirit in which 
the patients must be dealt with, the functions of the differ- 
ent house officers, are made plain, and the house rules are 
read and explained. ‘The necessity of obedience, of culti- 
vating one’s observing powers, of tact, of discretion of 
speech, of cultivating habits of reticence, of being respect- 
ful, faithful, punctual, teachable, and of paying attention 
to what is said, are dwelt on and emphasized. Every pupil 
starts out fairly, with a general knowledge of what is ex- 
pected of her during her probation. ‘The course of in- 
struction is similar to the one outlined in previous pages. 
Then the class is turned over to the supervising nurse for 
the first practical demonstration—usually, bed-making. 
These clinical demonstrations are given as frequently as 
opportunity affords during the first few weeks. When a 
patient vacates a room, the class is taken to that room and 
taught how to disinfect bedding, mattress, etc., how to 


PeEEEBRIMINARY, ERAINING 39 


fumigate and put the room in order. In all these practical 
lessons the minutest details are included. The chapters 
in the text-books on bed-making and the care of rooms are 
given them for study previous to the demonstrations. ‘The 
care of linen rooms and bath-rooms and sweeping and dust- 
ing are taught early in the course, and as soon as may be, 
after a trial of skill, the pupils are expected to assist in 
these duties. 

The class is divided into groups for practical work. Six 
hours of daily duty, divided usually into periods of two to 
three hours, in the hospital are required after a certain 
number of classes and demonstrations have been held. In 
a class of twelve two may be assigned to linen room and 
bath-room duty on two floors, two to diet-kitchen duty, 
tray-setting, and assisting in serving on two floors, two are 
under the direction of the chief surgical nurse and assist 
in making bandages and dressings after such duties have 
been explained and demonstrated, and two are taken into 
the wards and given personal instruction in methods of giv- 
ing baths and treatments. The group on treatments are 
allowed to assist the ward nurses in giving baths, rubbing 
backs of convalescents, combing hair, and making beds. 
They are expected to practise bandaging on each other. 
Massage demonstrations are given to the class, and oppor- 
tunity is given to practise on convalescent ward patients, 
as physicians may desire. There is a regular rotation of 
service in each of the duties, so that in three months a pupil 
has a fair working knowledge of the methods used by the 
institution. In the third month each nurse is given the 
responsibility of the nursing of one or two or more patients, 
in a ward, under careful supervision. Monthly written 
examinations are held, and usually each pupil is expected, 


400 PRELIMINARY TRAINING 


during probation, to write a short paper on some phase of 
nursing, as a test of her ability to observe and formulate 
her ideas and express them in writing. Instruction is given 
as to how to prepare their examination papers, how to mark 
charts and keep records—in fact, as far as it is possible to 
do so, the attempt is made to prepare a nurse for the 
practical duties for which she will be responsible. Daily 
classes are held, and a certain number of hours of study 
every day required. As compared with the old system, 
the results that are most in evidence are: more exactness 
in nursing; the cultivation of habits of study at the very 
beginning of the course; uniformity of method; and alto- 
gether more satisfactory service. ‘The new plan of training 
costs more in time and energy on the part of instructors, 
but the knowledge that the pupils are taught right methods, 
that they understand how to do the things required, the 
setting of high standards of practice in the beginning, the 
quality of thoroughness that shows throughout all their 
work, more than counterbalances the additional labor re- 
quired. 


CHAPTER V 
The Art of Teaching 


The graduate nurse who finds herself for the first time 
before a class in the capacity of teacher has usually some 
feeling of embarrassment. She may feel confident that 
she knows how to nurse, that she is able to care for a patient 
afflicted with any ordinary, or extraordinary, disease, but 
such knowledge does not always spell power when in the 
presence of a class. It does not always give confidence in 
an attempt to give theoretic instruction, to direct the pupil’s 
studies, and to do the work of a teacher. If she has had 
previous training in the art of teaching as a public school 
teacher, she may experience less difficulty in deciding how 
to take hold of a subject. 

In an attempt to secure practical suggestions that might 
be of use under such conditions the works and methods of 
a score or more of experienced educators, both in the hos- 
pital and general educational field, have been searched, 
and studied with a view to getting some light on methods 
of teaching that could be used to advantage in a hospital 
training-school. ‘The first point to be emphasized is that 
every teacher of any subject should have some method in 
giving instruction—that the method of teaching should 
be studied as well as the matter. How shall I teach this 
lesson? What general plan shall I use? What illustra- 
tions are available? Shall I begin with a question? If 


so, what question? Shall I begin with a statement? If 
41 


42 THE ART OF TEA CHG 


so, what statement? What are the important points to 
be dwelt on? What are the main points to be brought out? 
How can this lesson be taught so as to be of the most benefit 
to the class? How shall I close? What help can I give 
them in preparing for the next lesson? ‘These are ques- 
tions to be asked and answered before every lecture or 
recitation. ‘There is sound wisdom in having an end in 
view from the beginning and knowing how to reach it. 


METHODS OF INSTRUCTION 


The management of a training-school deals with its 
organization, the selection of its officers, its faculty, the 
arrangement of its curriculum, and with the correlation 
of all educational factors. 

Method deals with the principle upon which good teach- 
ing must be based, and with the means of making each 
subject in the curriculum produce the best educational 
results. How much teaching or how little each superin- 
tendent or head nurse shall do is a matter to be decided 
by each school and regulated largely by the extent of the 
demands made on the superintendent as an executive. 
officer. No one knows so well as a superintendent, who 
is a nurse, what instruction the nurses should have, and 
for that reason she should make it a point to attend at least 
some lectures in every course, until she is satisfied that the 
nurses are getting out of the lectures what they ought to 
get. It by no means follows that, because a man is con- 
nected with two or three hospitals and a medical school, 
he will give a satisfactory course of lectures to nurses. ‘The 
fact that he is in such demand is often a good reason for 
not depending on him. Some lesser light would in all 


PoE AR T OF TEACHING 43 


probability give more time to preparation and take more 
interest. Many schools have been crippled by depending 
on men who were too busy to attend to the work they 
allowed themselves to be advertised as doing. Judged 
by the benefit received by nurses, many courses of lectures 
advertised in the annual announcements have been bril- 
liant fizzles. 

In arranging a course of study great care should be taken 
to arrange it so that the work of the first year shall prepare 
the nurse for that which is to follow, that it begins with the 
fundamental general principles, and passes by natural 
order of progression to the special subjects. ‘Too little 
attention has been paid to proper grading of instruction 
in nurses’ training-schools, and as a result nurses are con- 
stantly doing things the importance and reason for which 
are not understood. 

At least five methods of instruction may be used to 
advantage in a hospital training-school in addition to reg- 
ular bedside instruction. 

Instruction by recitation, in which the pupil prepares 
herself by careful study of a prescribed section of a text- 
book. 

Laboratory exercise, in which the pupils perform for 
themselves various experiments under the supervision of 
teachers. 

Practical demonstration, in which the teacher performs 
for the whole class certain experiments during the process 
of demonstration. : 

Illustrated lecture, which may supplement the standard 
text-books or be entirely independent of any text-book, 
in which charts, blackboard, and all aids to aby are 
freely used. 


44 THE ART\/OF TEACH iis 


Conferences in which announced topics are informally 
discussed by teacher and pupils. 

The two great codrdinate aims of education are that 
people may acquire knowledge and develop power, and 
any method which helps in the attainment of these objects 
should be employed. 

“Teaching is simply helping the mind to perform its 
function of knowing and growing.” 

“Teaching, in its simplest sense, is the communication 
of knowledge, the painting in another’s mind the mental 
picture in one’s own mind, the shaping of a pupil’s thought 
and understanding to the compre of some truth— 
the making it common to the two.” 

“Teaching is arousing and using the pupil’s mind to form 
in it a desired conception or thought.” 

“Learning is thinking into one’s own understanding a 
new idea or truth.” 


ESSENTIALS OF TEACHING 

Teaching implies the existence of two factors, one im- 
parting, the other receiving, instruction. Professor Hart, 
in making a distinction between the hearing of recitations 
and the real teaching process, says: “A pupil recites les- 
sons when it repeats something previously learned. A 
pupil is taught when it learns something not known before. 
The two things often indeed go together, but they are in 
themselves essentially distinct. ‘Teaching is causing an- 
other to know.” 

If we accept this definition of teaching, we are forced 
to admit that much that passes for teaching is really not 
teaching. It is merely the repetition of facts or theories. 


ieee ak Tr OF TEACHING 45 


If these are not learned or grasped by the student, then no 
teaching has taken place, for teaching includes the two- 
fold process of imparting instruction and learning. Nei- 
ther part alone constitutes teaching. 

Four things are necessary to intelligent teaching: The 
teacher must know the pupils—their individual needs 
and attainments; she must know what she is to teach; 
she must know how to teach it; and there must be a com- 
mon language. The pupil must understand the words 
employed if learning is to take place. “The mind grows 
on what it assimilates,” and for this reason it is essential 
for the teacher to test the pupil’s knowledge and measure 
her ability before beginning the teaching process. This 
is perhaps more necessary in nurses’ training-schools than 
in many other departments of education, since in such 
schools are found pupils of very variable attainments. 
The young woman who never saw the inside of a high 
school and who had not attempted study for ten years 
before entering the hospital is put side by side with the 
college graduate who has all her life been a student. 
Natural ability will often overcome the lack of early edu- 
cation, but if they are to be graduated equally proficient, 
there must be some individual attention and direction 
as to methods of study. Individual defects should be noted 
and emphasized with a view to their correction. Poor 
penmanship and bad spelling are not insuperable diffi- 
culties, but they are decided disadvantages to a nurse and 
should not be deemed unworthy of notice. 

In addition to the teacher of nursing knowing what she 
is to teach, she must know whom she is to teach—not 
merely their names and how long they have been in the 
school, but their individual capacities, attainments, and 


4° THE ART OF TEACH is 


needs, their habits of thought, characteristics, and tend- 
encies. ‘Taking things for granted is a common failing, 
and rarely justifiable. ‘There is next to nothing of import- 
ance in the study of nursing, the knowledge of which it is 
safe to assume is possessed by the pupils until the actual 
test has been made. So as long as a nurse is supposed 
to know what she does not know, it will be impossible to 
cause her to understand clearly any fact in the regions be- 
yond where this primary knowledge is essential. No in- 
telligent physician would administer a prescription until 
he had studied the patient’s needs. No wise teacher will 
attempt to plant knowledge in a pupil’s mind until she 
has found that the pupil is ready to digest and assimilate it. 


SECURING THE PUPIL’S COOPERATION 


The manner in which the lectures and recitations are 
conducted will have much to do in holding the attention of 
a class. ‘To know how to make the subject matter stim- 
ulate the pupil’s mind to activity so that she will get posses- 
sion of the desired lesson is one of the teacher’s problems. 
This is a subject that needs always to be studied in advance. 
If successful mental work is expected of nurses, there should 
be an effective arrangement of the matter for them, going 
over the assigned portion of the text-book and emphasizing 
the important points, giving suggestions as to how to study. 
This is especially necessary with beginners. 

The necessity of careful grading of subjects has been 
mentioned, so that one step taken will prepare them for 
the next. Especially is this important in the junior year, 
when so many new ideas are crowding in upon the nurse 
and causing confusion of mind. Specific direction from 


Gat Ak)T OF FEACHING 47 


one who knows the ground thoroughly will save them from 
a waste of time, and anything that will save them from a — 
waste of time and energy is a help to them. Mere memory 
work is not the only-thing desired. The object of all teach- 
ing is the cultivation of intelligence in their particular 
branch, sound character, and the ability to apply their 
knowledge to practical conditions. 


THE RECITATION 

One of the primary objects of a recitation is to find out 
what the pupil knows and how she knows it. She may 
have memorized the exact words of the text-book and yet 
utterly have failed to comprehend the meaning of the sub- 
ject matter. Another object is to find out what the nurse 
does not know about the assigned lesson, and to aid her 
to a clear interpretation of the lesson. 

A fourth object is to explain difficulties upon which the 
class or any member of it may have exhausted their efforts. 
It is well to make it a general rule never to explain a point 
until the whole class has done its best upon it. 

A fifth purpose of the recitation is the development of 
the pupil’s powers of original expression. 

The whole recitation should be conducted for the bene- 
fit of the class, and pupils should be expected to recite to 
the class rather than to the teacher. The manner of the 
teacher should show alert interest, self-possession, and 
mastery of the subject of the lesson. No teacher should 
complain if she does not get attention or active interest 
from a class if she has not put vim, quickness, and force 
into it. 


48 THE ART OF TEACH Rigs 


THE ART OF QUESTIONING 


There are several distinct ends to be gained by proper 
questioning: stimulation of pupil’s mind; test of pupil’s 
knowledge of a subject; deepening of interest in a subject; 
and bringing out its important aspects and making them 
clear. 

In order to secure interest from the whole class no pupil 
should know when she is to be questioned. ‘The question 
should be asked before the pupil’s name is called. If the 
teacher says “Miss Jones, will you please tell us in how 
many ways medicines may be administered?” the atten- 
tion of the whole class will be relaxed as soon as Miss Jones’ 
name is called, and they may fail to apply the question to 
themselves. If the teacher had said, “ Will you please tell 
us in how many ways medicine may be given, Miss Jones?” 
each pupil would take in the full force of the question, not 
knowing but she would be called on to answer. 

Prompt questioning on the part of the teacher and 
prompt answers will help greatly in holding the attention 
of a class in the driest subject. 

There are certain kinds of questions to be avoided in 
all teaching, as, for instance, categorical questions which 
require only yes or no for an answer, as, “Is a low temper- 
ature more serious than a high one?” 

Another form of question to be avoided is the elliptic 
form, as, “The three vital signs are i 

A third form of question to be avoided is the suggestive 
form, as, ‘‘ Mustard is one of the common rubefacients, 
isn’t 1t?” 

Questions should be clear cut and free from ambiguity— 
not haphazard, ill digested, hesitating, or rambling. It is 
a good thing for each teacher to make her own questions, 


fat ART OF FEA C.HIN'G 49 


suggested by observation in class and intercourse with 
pupils, rather than use ready-made questions, though 
ready-made questions are often helpful and suggestive. 

Time spent in advance on questions is time well spent. 
Even old experienced teachers think them over carefully 
and often write them out. This latter plan helps as a 
guide to thought, phrasing, and in planning how to teach. 


THE REVIEW 

The primary object of a review is not to prepare a nurse 
for examination by a stuffing or cramming process. A 
well-conducted review is a test of thoroughness. It shows 
the pupil’s weakness and strength, their gains, their defici- 
encies, to themselves as well as to the teacher. A thorough 
review should result in correcting, completing, connecting, 
and fixing into permanent form the matter studied. ‘This 
testing work should go on in connection with the whole 
teaching process. Reviews should be frequent. A few 
well-planned questions at the beginning of a lesson, bring- 
ing out the most important phases of the previous lesson 
and a few at the close, briefly touching on the main points 
just brought out, will help to fix the matter in the nurse’s 
mind and make stated examinations less formidable affairs. 
It should be, in reality, a reviewing, rethinking, reknow- 
ing, and reproducing of the matter that has been assigned 
for study. 


THE EXAMINATION 
The objects of an examination are usually to test the 
fitness of the candidate to continue the course or to lay 
aside the work as completed or to determine their fitness 


for more advanced work. The test, to be of value, should 
4 


50 THE ART OF TEAC 


be a test of all the powers of mind and body that have 
been in training—not mere memory work. Both oral and 
written tests should be used. The direct value of the 
written method is that it gives an opportunity for careful 
thought and preparation before answering. ‘The indirect 
value is that it cultivates powers of expressing ideas in 
proper form. Its disadvantages are that it requires good 
powers of composition, which is a separate gift and is apt 
to be discouraging to pupils who are weak at this point. 

The lecture system in teaching takes it for granted that 
each pupil is ready and able to make an intelligent effort 
at acquiring the knowledge given out by the lecturer. ‘The 
taking of notes is an important part. The submitting of 
these notes for inspection and correction is fully as impor- 
‘tant. Its real value in a nurses’ training-school is a question 
on which there is a wide difference of opinion. A rambling 
lecture, lacking plan in the lecturer’s mind, cannot pro- 
duce any important results in a nurse’s education. Many 
nurses are not experts at seeing the important points and 
getting them down quickly. In medical schools there 
has been a decided change in methods of instruction in 
recent years. More reliance is being placed on study 
from text-books and the recitation plan, and less on the 
professor’s lectures. A distinct gain will be found in a 
nurses’ school when the text-book plan is more generally 
used in all the fundamental branches. Special lectures 
on subjects not generally included in text-books may be 
found helpful in the final year of training. 

The nurses should be encouraged to interleave their 
text-books, to take copious notes, to underline, and to use 
the margin freely in their studies. ‘The portions of the 
text-book which contain the lesson to be studied should 
be plainly indicated, and the important points emphasized. 


CHAPTER VI 


Examinations 


Examinations are generally admitted to be necessary in 
all educational institutions, even though there are times 
when one might feel justified, in a hospital, in classing 
them among the “necessary evils” of life. If the questions 
were asked, ‘What is your object in arranging for this 
examination of this class of nurses? What do you expect 
to accomplish by it?” the answer would probably be, “It 
is a test of the fitness of the nurse to go on with the course, 
or of her general proficiency, or of her ability to undertake 
more difficult work, or to determine wherein she is weak 
or deficient.” However valuable or satisfactory the 
written test may be in ordinary educational institutions, 
it is certainly far from being the best test in a hospital 
training-school. A nurse might be able to write per- 
fectly the theory of bed-making, and yet never keep the 
beds in her ward looking neat and trim. Like the pro- 
fessor at the skating-rink, she might be “up in theory, 
but down in practice.”” She might know all the methods 
of preventing bed-sores, and yet neglect to watch for their 
approach. She might be thoroughly versed in the rules 
for the administration of medicines, and yet be very careless 
in handling them. She might know all the facts that are 
known about sepsis and asepsis, and yet be a very indif- 
ferent surgical or obstetric nurse. 


That a nurse should be able to cram her mind with the 
51 


52 EXAMINATIONS 


facts concerning any subject, and take a high grade in 
theory, is of far less importance than that she should have 
proved herself strong and careful in the daily routine. 
The real work is a far more valuable test than the telling 
of it. The nurse’s improvement in it, and the result of 
frequent reviews, is a truer test than any written examina- 
tion, however thoroughly and fairly conducted. What the 
nurses can do, how steadily and resourcefully they can 
meet emergencies and manage difficult situations, their 
ability to get on with disagreeable people, their every-day 
faithfulness and accuracy, are of far more value in determin- 
ing their fitness to hold a diploma than their telling or 
writing what they would do under certain circumstances 
could possibly be. Perhaps the greatest value of the writ- 
ten examination is the fixing of the subject in the pupil’s 
mind and the discovery of weak points. This latter is 
often only an inability to express the knowledge possessed 
in proper form. ‘The greatest benefit of examinations is 
only realized when the ground covered in examinations 
is thoroughly reviewed in class. ‘Then the character and 
value and weak points of the answers can be clearly shown. 

The proper fair grading of a paper, the fixing of the 
value of each answer, or part of an answer, is not an easy 
matter. Before attempting to grade a paper, an examiner 
should have some general system of weighing an answer 
and determining its value. 


THE ANSWERS 
What are the elements of a good answer? An answer 
to be called good must, first of all, show thought. Ran- 
dom, haphazard answers deserve little credit even if 


EXAMINATIONS 53 


they almost hit the mark. A good answer will show 
clearness of expression. Ambiguity will be guarded 
against. In a good answer all that is asked will be given, 
but nothing more. A good answer will bear the mark 
of a correct interpretation of the question; this results 
from giving careful thought to each question before 
attempting to answer it. The reason for failure at this 
point can often be traced to the fact that the student did 
not take time properly to grasp the point. Good arrange- 
ment always characterizes a good answer. Many answers 
admit of clear, methodic arrangement. It is the student’s 
business to see these opportunities and use them. A good 
answer will give evidence of a proper appreciation of time, 
space, and words, and economy will be exercised in the 
use of all three. It is a common failing to give more than 
is asked for, because the student cannot give enough of 
what is demanded. While this failing should be discour- 
aged, it is unfair to reject as worthless any answer that 
contains even a small fraction of truth. Partial answers 
deserve partial credit. To sum up: The good answer 
must show thought, clearness of expression, correct inter- 
pretation, good arrangement, economy of time, space, 
and language. The answers that deserve no credit are 
those which show flippancy, thoughtless haste, guesses, 
and incorrect ideas concerning the subject. 


GENERAL RULES v 
With each class some instruction as to how to arrange 
their answers, how and where to affix their signatures, 
how to fold papers—general rules—must be given. These 
instructions might read similar to the following: 


54 EXAMINATIONS 


Candidates will write on one side of the paper only. 

The number of the question and not the question itself 
must be given. 

Questions need not be answered in the exact order in 
which they are written, \but must be numbered exactly 
as in the question paper, each subdivision being correctly 
indicated. y 

A line must be left between each question. Subdi- 
visions must always be started on a new line. An inch 
space must be left at the left side of the paper. 

New questions must not be started at the bottom of the 
page. 

Each page must be numbered in the right-hand corner. 

Papers must be folded lengthwise. 

Candidates will please be prompt in reporting for ex- 
amination and will bring with them pen, ink, blotter, and 
eraser. 


PREPARATION OF PAPERS * 

The preparation of short papers on nursing subjects 
at frequent intervals during the training period is a great 
help to habits of study as well as to clearness of expression. 

The following hints on how to prepare a paper have 
been used in getting nurses started in such work: 

In preparing a paper first think your subject through 
carefully and decide the main points you think should be 
touched on. Write those out in the order in which you 
intend to treat them. ‘Then make a skeleton, something 
on this order: 

Title—Surgical Cleanliness. 

Theme—Methods of Securing Cleanliness. 

Introduction—The Germ Theory. 


EXAMINATIONS 55 


Development— 

Conclusion— 

The introduction should be comparatively short. The 
main part of the paper should be given to the development 
of the subject. ‘The conclusion should usually be either 
a climax of ideas in the order of their importance or a gen- 
eral summing-up of the main points of the paper. 

Write first a rough copy. ‘Then let it rest a day or two 
or longer, and go through it and correct it before rewriting 
it. Criticize it ruthlessly. Notice spelling and punctu- 
ation. Arrange your paragraphs carefully. Short, dis- 
jointed paragraphs are to be avoided. As a general rule, 
each paragraph deals with a different aspect of the subject. 
Study to express yourself clearly. Avoid long sentences. 
Short sentences are clearer, more emphatic, less apt to be 
ambiguous. Aim to make each paper better than the last. 
Give most emphasis to important points. Study the little 
details which combine to make perfection. It is not suffi- 
cient to know all about a subject unless you can express 
clearly and in proper order what you know. When asked 
to write a paper, essay, or thesis, always keep it on separate 
paper from the main part of the examination. In the 
finished paper the divisions of the skeleton should not ap- 
pear, but the paper should bear analysis according to these 
rules. 


56 EXAMINATIONS 


TRAINING-SCHOOL RECORD 


Candidate’s name...... Date of entrance...... Probation ended... . 

[Nddress\ * seh asine seen ee APG) ini tras Be eer ree Religion ger eence 

Friend’s address....-..- Dateiof graduation). .2----05 =e eee eee 
onal Vane. eae AVERAGES. REMARKS. 

IWeportmentie ss anicie= = 

Health 2522 aac hehe = Practical 

Order and cleanliness. - work ... 

Theory of nursing... .- 

Ly SIEM sp ieidinecisiaeinleics Ist year... 

JNinvel| 50) 00), 4c ys ee ee 

ibbysiologyses seca sa - 

IDFGRMES. 5a o4de5 SSR 2d! years 

Bacteriology......---- 

Cookingee dence eee = 

Bandaging........---. 3d year ..- 

Surgical nursing....... 

Gynecology...--..---- Theory -... 

Obstetnicsss oye ees 


Materia medica....... 
Diseases of the nervous 

SV SLED Reet eiei 
Diseases of the eye, ear, 

nose, and throat .... ist year .. 
Contagious diseases - - . 
Children’s diseases... . adi yeat eae 
imerpenciesi-. -2oehae 
Diseases of the skin... 
General medical nurs- 


MIL hee eves elaine 
Wrinalysiss= = -e---<—- Total 
Wiassapes sce secec tai average .- 


Executive ability. ..-..- 


CHAPTER VII 


Fundamental Principles 


At the very beginning of the nursing course it is wise to 
take time to teach fundamental principles thoroughly. 
Once these are grasped, everything else is more easily 
understood. The nurse’s relation to the physician and 
to the patient should be clearly put before her. Instead 
of clinging to that old idea that may, in Sairy Gamp days, 
have been necessary, that may still be necessary in military 
circles, and that, unfortunately, is quoted by a few physi- 
cians today as illustrating the proper attitude of the nurse 
in relation to the care of the sick— 


“Yours not to reason why, 

Yours not to make reply, 

Yours but to do or die” — 
is it not well to try to teach her from the very beginning 
“to reason why,” “‘to make reply,” until she clearly under- 
stands what she is expected to do, what object the physi- 
cian has in view in giving certain orders, what results he 
expects ? 

Inasmuch as the average young woman has very chaotic 
ideas of what nursing really is, and usually associates it 
with a great deal of dosing and runnmg to and fro in waiting 
on the sick, it has been found wise to start out with a plain 
simple talk on what nursing is, what it involves, what it 
requires. If this is followed by another talk in the simplest 
possible language regarding what disease is; what some 

57 


S FUNDAMENTAL PRINCI Eee 


of the main causes are, such as unwise or excessive feeding, 
irregular habits, bad air, want of cleanliness, or any viola- 
tion of nature’s laws; how such conditions are corrected; 
what the physician’s part, the nurse’s part, and nature’s 
part is in the healing process—the nurse will speedily find 
her conceptions of the business she has undertaken en- 
larged. 

Remembering the great variety of perplexing questions 
that came to her in her early days as a nurse, when nursing 
literature was scant and systematic instruction according 
to a prearranged plan was practically unknown, the author 
has endeavored in dealing with her own classes to put 
before them at the beginning some of the general principles 
relating to the relief of human ills that ought to be under- 
stood by every intelligent person, but which, even in this 
age of enlightenment, are too little appreciated. The 
following general principles are cited, not as examples of 
the best way to arrange such a preliminary talk so as to 
prepare the class for the duties and for the instruction 
that will follow, but simply as suggestions that may be 
helpful to those who use this method for the first time. 

In any disease intelligent treatment requires that the 
history of the disease be known and also the history of the 
patient previous to the attack. The present: condition, 
not only of the affected part, but of the entire organism, 
should be ascertained as fully as possible. ‘The manifesta- 
tion of disease in one organ may be the result of disease 
of some organ near or remote, and while it is not always 
possible to discover the cause, it is, in the majority of cases, 
and the best results are obtainable when the cause is known. 
The work of diagnosis does not come in the province of 
a nurse, but she can render great assistance in that most 


oN DAMEN TAL PRUNCIP LE S59 


important and difficult part of medical practice by intelli- 
gent observation and knowledge of the principles under- 
lying the treatment of disease in general. 

One of the first principles of treatment is the removal of 
the cause of disease if possible. If the disturbance be due 
to impure air, secure pure air; if to unwholesome food, 
remove the cause of irritation from the system and cut off 
the supply; if to excessive heat, apply cold. Even in 
nervous cases, where the cause is often imaginary, it may 
be removed by diverting the attention to some other sub- 
ject and surrounding the patient with wholesome mental 
influences. 

A second principle of treatment is to administer no rem- 
edy unless it is plainly demanded. Indiscriminate dosing 
and drugging do harm oftener than good. Frequently, 
when the patient needs more than anything else an enema 
to relieve constipation and a good brisk walk in the open 
air, various powders and pills, the contents of which are 
unknown, are taken for the headache that would have 
subsided had the functions been properly regulated. 

A third principle is to refrain from administering a 
remedy without a clear idea of the benefit to be derived 
from it. Haphazard treatment in the hope that if it does 
no good it will do no harm usually results in doing harm. 
If no other harm is done it is an unnecessary drain on the 
vitality of the patient. Palliative treatment is often needed 
in obscure conditions where the real cause and nature of 
the disease are undetermined, but until a skilful physician 
has charge of the case, only the simplest measures for the 
relief of pain should be attempted. A certain class of 
people are prone to assume, without a knowledge of the 
conditions or demands of the case, that neglect only is 


60OFUNDAMENTAL PRIX 


dangerous. ‘This error, unfortunately, is not confined 
to the laity, and many physicians (happily the type is 
rapidly becoming extinct) torture the sufferer with new 
combinations of drugs every day or oftener. Half a dozen 
different drugs at a time are poured into them, these in a 
few hours reinforced by others, then abandoned and some- 
thing else tried. Anything seems desirable except to let 
the patient alone for a time and give exhausted nature 
an opportunity to reassert her power to heal. 

Another very important principle which should govern 
all who have to do with the care and treatment of the sick 
is to study the process of nature and endeavor to work 
harmoniously with her. In any form of treatment the 
immediate action and the remote influences of the remedy 
should be watched. ‘Nature is at work endeavoring to 
free herself from obstruction, to remove noxious elements 
from the system, or in some way to remove existing causes 
of derangement and restore harmony to the vital processes; 
but nature works blindly, she is not intelligent, and often 
destroys herself in the effort of self-preservation by too 
great intensity of action. Hence when the morbid pro- 
cess is becoming too intense it should be checked by the 
employment of well-known means for lessening vital action. 
The effort should always be made to restore as far as pos- 
sible the balance of vital activity in the different parts of 
the system, which balance is always destroyed whenever 
a part or the whole of the system is in a state of disease” 
(Kellogg). 

Another principle is to economize and conserve in 
every possible way the vital powers of the patient. De- 
pression and overstimulation are both to be avoided. ‘The 
choice of remedies is made of those which will accomplish 


aN yAMEN TAL (PRIN CEPLIE'S 61 


the result desired with the least tax on the vital forces. 
If there is doubt that the remedy will weaken by decreasing 
the vitality more than it will help by arresting the abnormal 
process, it is safer to omit it and trust to nature’s methods. 

The last principle of treatment that need be mentioned 
here is—in all cases nurse the patient, not the disease. 
This is perhaps the most important for nurses to remember. 
Itis a common error with the laity, and some others besides, 
to administer some medicine that some one has said will 
cure the disease, and leave the patient and his peculiar 
condition out of consideration or to go through a routine 
as if all patients were alike. 


REMEDIAL AGENTS 

In considering remedial agents Kellogg says it is impor- 
tant to remember that the benefit derived is not through 
the action of the agent upon the system, but through the 
action of the living tissue upon it. Food nourishes the 
body, but throughout the whole process of nutrition food 
is a passive agent, subject to the action of the living tissue. 
The same may be said of water and air. So in remedial 
agencies the medicinal property possessed by the agent 
is simply an expression of the manner in which the system 
receives it, and not the action of the remedy itself. A 
certain expenditure of vitality is involved in the use of all 
remedial agents, and the most desirable are those which 
will give the most assistance to nature’s efforts with the 
least drain on the vitality. 

Within the last decade there has been an increasing 
tendency to use as remedial agents those which are essen- 
tial to maintaining life and health under all conditions. 


62 FUNDAMENTAL PRINCIPLES 


In this class of remedies would be included water, air, 
light, heat, electricity, proper diet, exercise, and proper 
mental influences. ‘These natural agents are friendly to 
the vital functions, are in harmony with nature’s processes, 
and in many cases the regulation of the natural action of 
these agents is all that is needed to restore health. 

After years of experience in trying to arrange a satis- 
factory course of lectures on materia medica and thera- 
peutics for probationers and nurses in their junior year; 
: after finding often at the end of the course that the nurses 
had the most confused and chaotic ideas of the subject, 
owing to the lecturer’s excursions through these broad 
fields, a careful outline was made of the points that should 
be given to the class before attempting to study the doses 
and action of drugs. The following introductory lecture 
on the subject was prepared at the author’s request, and 
in conformity with such outline, and delivered by Dr. 
William Shields to the nurses of Columbia Hospital, Pitts- 
burg. It proved exceedingly helpful in getting before the 
class, at the beginning of the course, a clear, concise, and 
comprehensive idea as to the great variety of remedial 
agents that are in general use, and with which they, as 
nurses, should become’ familiar. Through the courtesy 
of Dr. Shields we are enabled to give the lecture in full: 

“Tn the treatment of disease we make use of various 
agencies which we call remedies. In the selection of these 
remedies we are permitted to avail ourselves of every pos- 
sible means for the prevention, cure, repair, or alleviation 
of bodily ailments. 

“We shall be limited in the study of materia medica 
mainly to the consideration of that class of remedies called 
drugs, yet it is proper for us here to take a comprehensive 


FUNDAMENTAL PRINCIPLES 63 


review of all the sources from which we derive remedial 
agents. 

“When we look at a list of all the remedies at our dis- 
posal for the treatment of disease, we find them almost 
as numerous as the diseases themselves. But for purposes 
of study we find that the entire list may be placed in com- 
paratively few classes. 

“Proceeding as nearly as possible in a logical order, 
we class remedial agents in the order of their relative im- 
portance. The old and trite saying that “An ounce of 
prevention is worth a pound of cure’ is nevertheless true. 
If the healing of disease be fraught with great blessing to 
humanity, how much greater must be any measure which 
guards human life from disease and injury. 

“Herbert Spencer, in his essay on education, in answer 
to the question, ‘What knowledge is of most worth?’ 
said: ‘As vigorous health and its accompanying high 
spirits are larger elements of happiness than any other 
thing whatsoever, the teaching how to maintain them is 
a teaching that should yield in moment to no other what- 
ever.’ - 


“PROPHYLACTIC REMEDIES 

“Hence we appropriately place at the beginning pro- 
phylactic remedies—those which have for their purpose 
the prevention of disease. Chief among these are sanitary 
or hygienic measures; the improvement of man’s en- 
vironment with reference to his air, food, exercise, water- 
supply, arrangement of dwellings, etc. 

“Much of the regulation of these outside influences is 
the work of public boards of health. 

“When applied to the individual, these measures pre- 


64FUNDAMENTAL PRINCIPOES 


suppose a knowledge on the part of the physician or nurse 
of the physiologic laws of the body and an acquaintance 
with the effects of food, clothing, climate, exercise, occu- 
pation, habits of life, ete., upon each particular body. 

“Under this class we allude to dieting, bathing, ventila- 
tion, change of residence, change of occupation, regulation 
of habits, especially those of breathing and dieting. 

“Dieting refers to the regulation, restriction, or selection 
of food, both in health and disease, together with a proper 
knowledge of the right methods of preparing the foods to 
suit the individual. 

“Bathing is a very important preventive of disease, as 
well as a valuable aid at times in the treatment and cure 
of abnormal states of the system. So important, indeed, 
is the use of water in the form of baths that many estab- 
lishments exist in this and other countries for the treatment 
alone of various acute and chronic diseases by means of 
water. As examples, in this country we are familiar with 
Cambridge Springs, Mt. Clemens, Clifton Springs, Sara- 
toga, and the Hot Springs of Arkansas; Carlsbad, Wies- 
baden, Kissingen, and others abroad. As nurses, you will 
have daily recourse to the use of bathing in one form or 
another, from simple sponging to the plunge or tubbing 
of patients, hot or cold shower-bathing, ete. 

“The use of water in the treatment of disease is as an- 
cient as the world, and it forms a most important part of 
the literature of medicine in all ages. 

“Ventilation regulates the supply and quality of air in 
the living rooms and is also a means of modifying. many 
disease processes, so as to hasten or facilitate recovery. 

“Breathing—proper method. 

“Climate. By this we refer to the character of a locality 


BUNDAMENTAEL PRINCIPLES 65 


as regards the prevalent atmospheric conditions, its tem- 
perature, moisture or dryness, purity or contamination, 
electric conditions, and other qualities. These atmos- 
pheric conditions are largely influenced or modified by the 
presence or absence of mountains, forests, lakes, rivers, 
also by altitude, latitude, proximity to the seashore, and 
the effects of trade-winds and ocean currents. 

“All these conditions may be utilized for their sanitary 
or physiologic influence upon the human body, both in 
health and disease. ‘These represent perhaps the most 
important of the prophylactic remedies and are very often 
called upon alone or in connection with other remedies 
or medicines in the treatment of disease. Thus we find 
that to properly regulate the ventilation and temperature 
of the sick-room, to direct the bathing and diet of the pa- 
tient, and to decide whether he shall have rest or exercise, 
is of as great importance ofttimes in facilitating the recovery 
as the nicely adjusted prescription. 


“TMPONDERABLE REMEDIES 


“We next consider a class of remedies which, because 
they are invisible and practically without weight, we call 
imponderable remedies. 

“Among these are light, heat, cold, electricity, mag- 
netism, etc. ‘These exist or have their source in the phe- 
nomena of nature, and when wisely applied, either alone 
or in modified states, are capable of powerfully influencing 
the bodily functions, both as sanitary and curative agents. 

“Thus we apply heat to the entire surface of the body 
for its stimulating or restorative effect upon the circulation 


or secretions, or we may apply it locally in circumscribed 
5 


66F UNDAMENTAL PRINCE 2s 


areas to allay pain or restore activity to some injured part. 
Hot-air machines which produce a high degree of dry heat 
are now quite generally in use in hospitals. 

“Cold likewise is valuable as a remedial agent in arrest- 
ing the progress of inflammation; thus we apply ice poul- 
tices to an abscess or over the abdomen in peritonitis or 
appendicitis. Cold is of great value sometimes in arresting 
the flow of blood and in reducing high temperatures. 

“Tight is also a useful agent in the treatment of some 
forms of disease. Direct rays of the sun are ofttimes essen- 
tial to the restoring of healthy color and vigor in weak or 
anemic patients. ‘These rays may be modified or sep- 
arated by means of prisms so as to obtain certain individual 
rays, which seem to exert special curative influence upon 
disease of a local nature. Along this same line we have 
certain electric rays of a powerfully penetrating character, 
such as the well known a-rays of Réntgen, which are now 
used with more or less success in treating cancer, lupus, 
and many other skin diseases. The wz-ray is also used for 
facilitating exact diagnosis of fractures. ‘These rays have 
the quality of penetrating the soft tissues of the body, and 
may often be an invaluable aid to the surgeon in locating 
foreign bodies, such as bullets, ete., which call for removal 
by surgical operation. 

“Electricity in the form of direct or indirect currents, 
magnetism, galvanism,-is constantly being used with much 
apparent success as a curative agent, especially in connec- 
tion with massage, of which you will learn later. 

“We now come to another class called mechanic reme- 
dies. 


PEN DAMEN TAL PRIN CIP LES 67 


“MECHANIC REMEDIES 


“This covers the domain of surgery and certain me- 
chanic and surgical procedures, such as acupuncture, or 
bleeding into the tissues of the body by means of a needle 
puncture. 

“ Acupressure—compression of a blood-vessel under the 
surface by inserting a needle over it. (Not much used at 
present. ) 

“Bandaging, as to support a fracture or a sprain, or to 
retain other dressings in place. 

“Blood-letting, as by opening a vein, applying leeches, 
wet-cupping, ete. (Not much used.) 

“Finally, various forms of massage, gymnastics, Swedish 
movements, active and passive motion, mechanic vibra- 
tion. 

“Massage is the term applied to one of the most impor- 
tant of the mechanic methods of treating disease. 

“Tt consists of certain manipulations of the soft tissues 
of the body with a view to bringing about physiologic 
changes and improvement in general nutrition of the parts. 
In other words, it constitutes a practical substitute for 
exercise in persons who, by reason of disease or other in- 
firmity, are prohibited voluntary exercise. The practice 
of massage, both in health and for remedial purposes, is 
a very ancient one, and has been used in all ages and among 
all races. It is a most valuable ally in the treatment of 
many diseases—so general have its uses been that one en- 
thusiast by the name of Still, of Missouri, about twenty- 
five years ago, conceived the notion that 95 per cent. of all 
diseases were dependent upon certain conditions of the 
bones, spine, etc., which could be readily cured by means 


68FUNDAMENTAL PRINCIPLES 


of massage and various manipulations of these parts. So 
he established the so-called school of osteopathy. 

“The fallacy of this idea lies in the fact that there can 
be no system of remedies which will apply to all diseases, 
except that system which recognizes the whole wide realms 
of nature, art, mechanics, man’s ingenuity, and God over 
all, as the sources whence to obtain the remedies. No 
other system is logical or adequate. 


“MISCELLANEOUS REMEDIES 

“T wish now to mention several other remedial agents 
under a miscellaneous class, some of them overlapping 
those groups we have already referred to. 

“Among these we have the serum remedies or antitoxins, 
counterirritation, clysters, hypnotism or suggestion, ete. 
By counterirritation we mean any method whereby the 
surface of a part of the body is irritated for purpose of de- 
flecting or changing the blood-supply from some deeper 
part to the surface. ‘This is done to relieve pain and may 
be accomplished by means of heat, tincture of iodin, or by 
the familiar mustard-plaster. 

“By clysters we refer to the injection of fluids into the. 
bowels (more commonly known as an enema) or into the 
circulation by hypodermic injection or transfusion. ‘The 
term enteroclysis means an injection into the bowel or 
enema. 

“Hypodermoclysis means the infusion of solutions into 
the circulation by inserting the needle beneath the skin 
and allowing the fluid to flow into and be absorbed by the 
tissue. 

“Blood may be transferred from one person to another 


Stow OAM EN TAL PREN CEP L §£'S69 


by uniting the veins and allowing the blood to flow across 
by the process called transfusion. 

“One of the most recent additions to our list of remedial 
agents is the serum treatment, or antitoxins. 

“These are growing in number, but the most familiar 
one, as well as the best established, is diphtheria antitoxin. 
It has for its basis a serum obtained from healthy horses 
which have previously been inoculated by the true diph- 
theria germ. ‘This process of preparing antitoxin will be 
explained to you later, but for present purposes it is suffi- 
cient to state that the effect of this serum when injected 
into the tissues of one who is infected with diphtheria or 
membranous croup is to so change the nature of the tissue 
that these germs can no longer live, hence the very cause 
of the disease is removed. 

“This is the ideal object in the treatment of all disease, 
and we may indeed expect great progress in therapeutics 
when the serum treatment has been perfected at the hands 
of scientists. 

“The death-rate from diphtheria under the former 
methods of treatment was very high,—15 to 20 per cent., 
—hbut under the antitoxin it is reduced to about 3 to 5 per 
cent. 

“Hypnotism or suggestion in one form or another plays 
a most important part in the every-day practice of medicine. 
The influence of the mind over the various functions of 
the body cannot be ignored, and every intelligent nurse, 
as well as every experienced physician, will be glad to en- 
list the help of such a powerful influence in controlling 
their patients. Ofttimes when the physician despairs of 
getting any effect from his remedies he may accomplish 
wonders by simply explaining the action of the remedies 


70FUNDAMENTAL PRINCIPLES 


to his patient, who unconsciously allows his mind and will 
to favor the results desired. 

“And is it not the experience of almost every physician 
to have among his patients some who express such bound- 
less confidence that the sight or presence alone of the doctor 
is sufficient to quell their aches and pains, relieve and cheer 
their drooping spirits? In like manner we see the mother 
kiss the baby’s bruise and the pain vanishes instantly. 

“So we find that mental impression in the form of sug- 
gestion may be used, and has been used for ages, in the 
treatment of some forms of disease, especially those of a 
nervous type. 

“These suggestions have sometimes taken the form of 
superstition. The ancient custom of wearing amulets 
or fetichs for warding off disease has not entirely disap- 
peared even among civilized and enlightened people. 
Wearing rings to cure rheumatism, amber beads for the pre- 
vention of croup, is common. 

“‘And then we have our more modern fad called Chris- 
tian Science and faith cure, which, like osteopathy and 
similar cults, find their followers among those who are ig- 
norant of the laws of physiology and scientific truth. 

“Much harm and sometimes even loss of life has 
resulted from the ignorant practices of these followers 
after a delusion. 

“Music has its place also as a therapeutic agent in many 
forms of nervous derangement, and its action may be util- 
ized with great benefit in proper cases. 

“Leaving all other remedies, we now come to that class 
which we speak of as medicines or drugs. 


PEN DAMEN TAL PRINCIPLES 71 


*“ PHARMACOLOGY 

“The study of drugs is called pharmacology, or the 
science of drugs. 

“Tt embraces the study of the sources of drugs and all 
knowledge bearing upon their botany, chemistry, prepara- 
tion, physiologic action, medicinal use, poisonous effects, 
etc. 

“For convenience we will make four subdivisions— 
pharmacology, materia medica, therapeutics, pharmacy, 
toxicology. 

“‘Materia medica is devoted to the study of the sources 
of drugs, their botany, chemistry, derivatives, ete. Also 
their effect on the living body, in health, called physiologic 
action, and their action on the body in disease, called ther- 
apeutic action. ‘These two actions of drugs, or rather the 
action of drugs under these two conditions, viz., health 
and disease, is known as pharmacodynamics. 

- “Pharmacy is the art which analyzes and identifies 
drugs, provides useful and attractive forms of administra- 
tion, thus aiding the physician in applying the remedies 
he prescribes in a convenient and palatable form and in 
exact proportions and doses. 

“Toxicology studies the poisonous effects of drugs, 
together with their proper antidotes, both physiologic and 
chemic, as well as any other means of combating or an- 
tagonizing the effects of poisons in the body. 


“THERAPEUTICS 
“Therapeutics is that branch of pharmacology which 
deals with the application of drugs in the treatment of dis- 
ease. 


W2FUNDAMENTAL PRINGiET 


“Therapeutics, however, has a wider application, as 
you already know, since there are so many other sources 
of remedial agents, and so we speak of therapeutics in a 
broad sense as pertaining to the treatment of disease by 
whatever measures we deem best suited, and its application, 
therefore, embraces all that relates to the proper care of 
the sick. 

“Therapeutics embraces, indeed, the ultimate purpose 
of all medical science. It is the superstructure of which 
all other medical study is the foundation. Whatever po- 
sition a remedial agent occupies in medical science is 
dependent entirely upon its power or usefulness to modify, 
cure, or prevent disease; and so, after we have studied 
carefully the physical, chemic, and other properties of 
drugs, and the remedial value of all other agencies, for 
treatment, we are prepared to apply them in their appro- 
priate cases and they then become therapeutic agents. 

“Therapeutic agents are of two classes—natural ther- 
apeutics and applied therapeutics. 

“Natural therapeutics refers to the operation or processes 
of nature in curing or modifying disease independently 
of man’s art. We must all recognize the fact that the 
human body carries within itself the means and power to 
cure or modify all its curable diseases. ‘This it does by 
means of a powerful spontaneous force which has been 
called the ‘vis medicatrix nature.’ 

“A further truth in this connection is that all our at- 
tempts to apply remedies for the cure or alleviation of dis- 
ease can at best be but aids to these great natural forces 
of which we have just spoken. All healing must be the 
work of nature. Man’s art can only assist. 

. “Tt is when the destructive forces of nature threaten to 


mUNDAMENTAL PRINCIPLES 73 


destroy life by overpowering the forces of repair that man’s 
art comes to the aid of the latter and ofttimes wins the 
victory over disease. And in this silent contest with dis- 
ease the trained nurse stands as the strong right arm of 
the physician. Without her vigilance and careful admin- 
istration of the physician’s orders many lives would be 
lost, and the world would be a darker place for many 
hearts. 

“The word therapeutics is derived from the Greek, and 
means ‘to attend upon.’ 

“When we speak of the various means of treatment we 
generally prefix the name of the remedy or method em- 
ployed, as electrotherapy—electric treatment; mechano- 
therapy; hydrotherapy; psychotherapy; serum-therapy; 
massotherapy; radiotherapy; climatotherapy; pneumo- 
therapy.” 

The very same difficulty mentioned in the teaching of 
materia medica, the neglect to get the fundamental prin- 
ciples of a subject clearly before a class at the beginning, 
has been experienced in many of the other subjects. It 
seems to be difficult for many teachers who are experts in 
a particular branch to organize the knowledge they desire 
to convey, and also to give it in terms that are intelligible 
to those not familiar with the subject. A statement that 
appears perfectly clear and lucid to the lecturer will be as 
Greek to the class. In dietetics, obstetrics, and bacteri- 
ology the nurses, many times, seemed to have great diffi- 
culty in knowing how to get hold of the subject. Com- 
paratively few lecturers among physicians were willing to 
pay much attention to text-books prepared for the use of 
nurses, and the same was true of dietitians. ‘The dietitian 
wanted to use the books of her own school. The physician 


AFUNDAMENTAL PRINCGCIP®@ a 


had his choice of books, and both began at a different point 
in the subject from the books the nurses possessed, if they 
possessed any. Believing that the subject of dietetics 
was too important to be dealt with haphazard, text-book 
after text-book was purchased in the hope of getting the 
essential points about nutrition, arranged in concise form, 
that could be readily given to a class at the very beginning 
of their study of the subject. Before finding a text-book 
that really seemed to meet the case the author arranged 
and gave to her own classes the introductory lecture that 
follows. ‘This the nurses were obliged to study before the 
class was turned over to the teacher of dietetics for dem- 
onstrations, or to take up the details regarding different 
articles of food or to attempt practical work in cookery. 
Once the substance contained in this introductory lecture 
was grasped, the whole subject became more interesting, 
because easier of comprehension. Each point was elab- 
orated, explained, and illustrated as far as possible until 
it was plain to even the dullest student. 


THE PRINCIPLES OF NUTRITION 


The nutrition of the body includes four distinct pro- 
cesses: 

.First, the secretion of the digestive juices and their action 
upon food in the alimentary tract. 

Second, the absorption of the food-elements, when diges- 
tion is completed, into the blood-vessels and lymphatic 
vessels. 

Third, the assimilation, by the tissues, of the nutritious 
elements. 

Fourth, the elimination of waste matter. 


MeN AMEN TAL PRINCE LTLPLES 75 


Food has been defined as that which, when taken into 
the body, builds up its tissues and keeps them in repair, 
or which is consumed in the body to yield force and heat. 
Physiology teaches that every_act, thought, or feeling 
breaks down some portion of the cell-tissue from which the 
body is formed. If life is to continue, this broken-down 
tissue must be replaced. A certain amount of force or 
energy and heat must also be generated, and this comes 
also from the food that is eaten. The aim before every 
one intrusted with the care of the sick should be to provide, 
in proper form and proportion, as adapted to each indi- 
vidual, the food or nourishment necessary for these pur- 
poses. 


CHEMIC COMPOSITION OF THE BODY AND OF FOOD 

The chemic substances of which the body is composed 
are very similar to those of the foods which sustain it. 
From fifteen to twenty elements arefound. Those which 
exist in greatest abundance are oxygen, hydrogen, carbon, 
nitrogen, calcium, phosphorus, and sulphur. ‘These ele- 
ments are combined in both body and food, the most im- 
portant compounds being protein, fats, carbohydrates, 
mineral matter, and water. 


CLASSIFICATION OF FOODS 


There are a number of methods of classifying food-sub- 
stances. ‘These may be divided into organic and inorganic 
foods, the organic foods embracing the foods derived from 
the animal and vegetable kingdom, and the inorganic or 
mineral foods, consisting chiefly of water, common salt, 
and the other mineral constituents of the body and of food. 


46 FUNDAMENTAL PRINCI 


Again, food-substances may be divided into two general 
classes, nitrogenous and non-nitrogenous, the nitrogenous 
foods furnishing the greater proportion of material needed 
for tissue-building, and the non-nitrogenous, those needed 
for the production of heat and force. ‘This classification 
is not strictly correct, as nitrogenous foods do, under cer- 
tain conditions, contribute to the production of heat and 
force. ‘Their most important function, however, is tissue- 
building. 

Nitrogenous foods are derived both from the animal 
and vegetable kingdoms. Among the principal animal 
nitrogenous substances are albumin, found in the white 
of an egg, casein, found in milk, fibrin, found in blood, 
myosin, which is an important ingredient of muscle, and 
gelatin, which is derived chiefly from bone and liga- 
ments. 

The chief vegetable nitrogenous substances are gluten, 
a substance found in all cereal grains, and legumen, exist- 
ing largely in all kinds of beans and peas. It should be 
noted that peas and beans are tissue-building foods and 
may often be used to replace meat or other animal foods 
for persons whose digestion is unimpaired. 

The principal non-nitrogenous foods are: starch, a sub- 
stance found in many vegetables; sugar, found in plants 
as cane- or beet-sugar, and also in animals as milk-sugar; 
gums, found in plants; and fats and oils, derived from both 
the animal and vegetable kingdoms. 

The following list of foods may, therefore, be expected 
to provide material for growth and repair of tissue: 

Milk. Fish. Peas. 


Eggs. Cheese. Lentils. 
Meat. Beans. Peanuts. 


MUON DAMEN TALE PRINCIPLE S77 


The following foods may be expected to produce heat 
and force or energy: 


Cereals. Potatoes. Fats. 
Corn. Tapioca. Sugar. 
Rice. Sago. 

Vegetables containing little or no starch are: 
Cabbage. Egg-plant. Onions. 
Asparagus. Artichokes. Rhubarb. 
Spinach. Tomatoes. Pumpkin. 
Celery. Squash. Cauliflower. 
Green beans. Cucumbers. Fruits. 
Parsnips. Lettuce. 

Turnips. Radishes. 


These vegetables contribute largely to the salts, acids, 
water, and other mineral substances needed for the body, 
and especially for the formation of bones and teeth. 

There is a certain woody or tough fiber in many veget- 
ables which, while indigestible, yet performs a useful func- 
tion in contributing to the bulk of food needed, thus stimu- 
lating peristalsis. ‘These vegetables contain little real 
nourishment in proportion to weight, and are not valuable 
for persons with weak digestive organs. For healthy 
people they afford a pleasing variety. 

A common classification of food according to chemic 
ingredients is into four principal classes: protein, fats, 
carbohydrates, and minerals. i 

Protein is the term used to include the principal nitrog- 
enous compounds, whether animal or vegetable. These 
elements form the basis of bone, muscle, and other tissues, 
and are essential to the human structure. It should be 
remembered that each food-substance contains a number 
of different elements, but is classified according to the one 
that predominates. 


?WFEFUNDAMENTAL PRINCI 


DEFINITIONS 


The term albuminoids is used to include substances 
similar to the white of egg (albumen), the lean of meat 
(myosin), the curd of milk (casein), and the gluten of 
wheat. 

The term gelatinoids is used to include the substances 
-obtained from bone, tendons, gristle, ete. 

The term proteids is used when albuminoids and gelat- 
inoids are classed together. 

The term extractives is used to denote the ingredients 
found in meat-extracts, broths, ete. 

An erroneous idea prevails that boiling meat renders it 
valueless as nourishment when cooked in bulk. The 
albumin of meat is not readily dissolved or extracted by 
water. The salts and oils that give flavor to meat are 
largely extracted, but the remaining material contains 
a large proportion of the protein of the meat, and is capable 
of as complete digestion as the same weight of unboiled 
meat. With the addition of salt and vegetables for flavor- 
ing, it forms a nutritive food. Fats are found in meats, 
the yolks of eggs, fish, cream, butter, certain nuts, olives, 
oatmeal, and some other cereals. 

Carbohydrates is a term used to denote such compounds 
as starch, sugar, and vegetable fiber. ‘They are found 
chiefly in the vegetable kingdom, and abundantly in cereal 
grains and potatoes. In the body, carbohydrates may be 
transformed into fat when more food than immediate 
necessity demands is eaten; the surplus may be stored in 
the body as a reserve supply. This supply may be needed 
when, for any cause, food cannot be taken in sufficient 
quantities to repair the waste. 


men ANE NP AE PREN CE PL ES 79 


WATER / 

More than two-thirds the weight of the body is water. 
The uses of water in the body are: 

It renders the tissues soft, elastic, and flexible. 

It dissolves nutritive substances and conveys it in fluid 
form to the various parts of the system. 

It assists in the distribution of the heat generated in the 
body. 

It assists in the processes of absorption and secretion. 

It assists in carrying off the waste material. 

It moistens the skin and surfaces and acts as a lubricant, 
preventing friction. 


COMPLETE FOODS 


Milk and eggs are known as complete foods, the former 
contributing all that is necessary for the life and growth 
of the young animal or infant, the latter furnishing the 
material for the complete development of the young bird 
until it is hatched. There are three reasons why milk 
cannot be considered a perfect food for adults. “The 
proportion of water is so large that great quantities would 
have to be consumed in order to obtain the necessary nu- 
triment. ‘The protein is present in rather large quantities 
as compared with the fats and carbohydrates. It is a well- 
recognized fact that the digestive functions require that the 
food shall have a certain bulk other than water.’’* 


* In the preparation of this lecture the author used as references the 
works of J. Burney Yeo, W. Gilman Thompson, and the bulletins of 
the U. S. Department of Agriculture. Of all the text-books that have 
appeared in recent years on the subject of dietetics for nurses, two that 
have proved of special value in training-school work are ‘Dietetics for 
Nurses,” by Friedenwald and Ruhrah, and “Practical Dietetics,” by 
A. F. Pattee. 


CHAPTER VIII 


Teaching Dietetics 


While we gladly admit that we are gaining ground in 
the practical application of diet to disease, yet we must 
also admit that much less emphasis is even yet placed on 
this subject in hospitals and training-schools than the im- 
portance of the subject demands. Mrs. Ellen H. Richards, 
the well-known authority on the subject of scientific feed- 
ing, says—and who can doubt the statement ?—“ At present 
there are comparatively few persons who are called upon to 
feed the sick to whom a glass of milk or a pound of beef 
represents any definite amount of food materials; still 
fewer who can tell how much food value a glass of lemon- 
jelly or wine whey represents, and yet the adult patient 
is dependent upon the attendant, even more than the week- 
old infant, for the requisite nutrition.” Not only are the 
young women who enter our hospitals lacking in this knowl- 
edge of food values, but many of them have no more 
definite idea of how to prepare food for invalids than they 
have of medicine or surgery. It is quite evident that some 
instruction in dietetics is needed. ‘The question is, how 
much? ‘To maintain due proportion in the time allotted 
for each subject in a nursing course is not always easy. 
It requires a well-arranged plan at the beginning of a 
course and a careful adherence to it unless it has been 


proved to be not a good plan. 
80 


meee ent NG: DME BET 1 €'s 81 


HOW MUCH SHOULD A NURSE KNOW? 

How much should a nurse know about foods? How 
much time should be allotted to it? Considering the mul- 
tiplicity of important things that are clamoring for a nurse’s 
attention during her first year, how much about foods 
ought we to try to put in the first-year studies? If she 
gets a clear understanding of the main principles of nutri- 
tion, of different classes of diets, and practical instruction 
and experience in the methods of preparation of foods suit- 
able for invalids, it is perhaps all that she can reasonably 
be expected to manage in the study of dietetics in her junior 
year, if she does justice to other branches of nursing studies 
that are equally important for successful work. Even an 
elementary study of the principles of nutrition would in- 
clude the chemic composition of the body and of food, 
the sources from which food is obtained, the various ways 
of classifying foods, the uses in diet of water, protein, carbo- 
hydrates, fats, and salts. It would also include lists of 
foods for tissue-building and for the production of heat 
and force. From the knowledge thus obtained the nurse 
should know how to make up suitable menus for any of 
the common classes of diets and to give reasons for includ- 
ing and excluding foods from those lists. She should know 
something definite concerning the food value and the proper 
methods of preparation of fluid foods and beverages, so 
that she will not be guilty of the double blunder of making 
tea of water that was not boiling and calling it “nourish- 
ment” in her bedside record. She should know how to 
administer milk in all its varied forms and disguises so 
that it will be suitable to the taste, and also in the best 


condition for assimilation. She should know the effect 
6 


82 TEACHING DIETER Ge 


that boiling or pasteurization has upon the digestibility 
of milk and of the best means of diluting it for weak stom- 
achs. It would take a good deal of time to thoroughly 
study milk, but she ought to know a good deal about it. 
The same may be said concerning eggs. A nurse who does 
not know how to prepare eggs in a variety of ways, and 
serve them in an attractive manner, and who does not take 
pains to please both the eye and the palate, is unworthy 
of the name nurse. 

In the elementary study of flesh foods, the nurse should 
know at least the relative digestibility of the different kinds 
of flesh foods, and how best to cook the foods, so as to get 
for her patient out of the meat the maximum amount of 
nourishment with the minimum tax on the digestive 
powers. She ought to know how to make and prepare 
a variety of meat and vegetable soups and purées, and 
should know the nutritive value of vegetables, as well as 
how to cook and serve them attractively. 

How much should a nurse know about bread? She 
ought to know the difference in the food value of the white 
and brown breads, but more important, by far, than that, 
she should know how to “fix” bread, arrange it for her 
patient so that the sight of it will make him want it, rather 
than repel him. By all means she ought to know how to 
make a respectable piece of toast—one that is not burnt 
on one side and white on the other, one that is neither 
dabbed with butter in patches, nor soaking with melted 
butter. 

Besides this, there is a good deal that she should know 
about desserts—how to make them dainty and attractive 
looking, as well as how to calculate from the ingredients 
how much real nourishment her patient is getting from 


ire yAsC Ll N Gs DUE IE Tl cs 83 


each one. And the same may be said of the miscellaneous 
dishes—the salads, croquettes, dressings, etc. 


SECOND-YEAR STUDIES 


The study of foods in the second year might very prop- 
erly be in its application to different diseases, the results 
of dietetic errors, contamination and adulteration of foods. 
Perhaps this seems a good deal to require of a nurse in the 
line of dietetics, but she at least ought. to know as much 
about foods as the patients she will be called on 
to nurse. The twentieth-century patients read and think 
on the subject of rational feeding. At least many of them 
do. The popular magazines and newspapers of the day 
are replete with articles on the subject of proper feeding, 
and ignorance in a nurse on that highly important subject 
is utterly inexcusable at this period in the history of 
hospitals and nursing. 


EXTREMES TO AVOID 

Between two extremes the path of wisdom is usually 
found. Both of these extremes are found today in the © 
hospital world as regards the teaching of dietetics. On 
the one hand, we have hospitals that retain nurses for a 
three-year training, and give practically no instruetion in 
the subject. In one small hospital with whose conditions 
the author is familiar—and there doubtless are many of 
such hospitals—the entire preparation of food, the setting 
of trays, and the serving are intrusted to untrained maids. 
The nurses graduate without even having been required 
to set a tray for a patient. In other institutions some 
theoretic instruction is given which, “falling upon more or 


84 TEACHING DIETER. 


less stony ground, brings forth scanty fruit or a good crop 
according to circumstances.” On the other hand, we 
have instructors of nurses who assert that a nurse cannot 
know too much, and who, therefore, propose to teach them 
all that can possibly be of any practical value, and a great 
deal besides that can be of very little use in nursing the 
sick. What possible good it can do for nurses to spend 
time in learning how to apply the flame test for sodium, 
potassium, calcium, strontium, by borax bead and Bunsen 
burner, is a question too deep for the average mind to 
answer. What practical benefit can it be to the average 
patient or satisfaction to a doctor to have a nurse who 
knows the deep mysteries of sugar, and can make a com- 
parison of sucrose, glucose, levulose, lactose, or who can 
explain their preparation, composition, properties, diges- 
tion, and food value? Just how much further probationers 
and pupil nurses will be asked to go in the study of chem- 
istry, pharmacy, bacteriology, and pathology in the next 
ten years—where we may expect to stop in our attempt to 
teach nursing—is a matter for speculation. A good many 
people believe we have reached a time when it is necessary 
to draw the line and popularize the slogan, “Back to 
nursing!” 

Between the extremes cited there is a growing number 
of institutions that have taken a sensible middle ground. 
They have worked out a course in dietetics that gives nurses 
intelligent instruction in the foundation principles of the 
subject, that teaches the kinds and proportions of various 
foods required to maintain the body in health, the cal- 
culation of food values, the modifications in the methods of 
preparation that are required when dealing with the sick, 
something about foods suitable for special conditions, 


fea ch UNG DIE PET TCs 85 


infancy, childhood, adult life, and old age, something about 
the contamination of foods, the diet required in different 
climates, a good deal about digestion and dietetic errors 
and diet in disease; a course that gives much attention 
to practical work, attractive cookery, and artistic serving; 
to methods of administering food to the sick, the feeding 
of helpless, unconscious, or insane patients. Besides this, 
such a course should include some instruction in market- 
ing, how to determine the quality of flesh foods, milk, 
vegetables, and groceries; the care of kitchens, pantries, 
refrigerators, and cooking utensils. 

Special emphasis needs to be placed on the preparation 
of foods designed especially for use in illness, the prepara- 
tion of beef-juices, broths, jellies, and the modification of 
milk for various diseased conditions. 

The introduction of a practical sensible course into train- 
ing-schools has meant a very decided improvement in 
the whole dietetic department of many institutions. And 
it may safely be said that no real improvement in training- 
school methods can be effected without raising the standard 
of the hospital. This is the universal rule when intelli- 
gence and skill take the place of ignorance and haphazard 
work. The thing to regret is that so many hospitals have 
not seen fit to bring scientific teaching to bear on this 
department. One of the weakest points in the whole 
machinery of many hospitals has been, and still is, the 
dietetic department. Physicians have found, and still 
find, it impossible to secure for their patients the special 
diet the conditions demand. Patients complain of the 
food, of the way in which it is served, and of the lack of 
delicacies or really appetizing variety. Friends of patients 
still, patiently or impatiently, carry, day after day, to 


86 TEACHING DIE TE Mee 


many modern hospitals, delicacies for private patients 
who could not relish the food provided, delicacies that the 
hospitals should provide. It is manifestly impossible to 
please everybody, but in the great majority of instances 
there is reason for complaint. The picture drawn by 
Mrs. Richards in her papers on ‘ Hospital Dietaries” 
is altogether too realistic to form pleasant reading for 
those who carry hospital responsibility. “I have seen,” 
said she, “a delicate girl with a very sensitive stomach 
served with a tray full of meat, mashed potato, squash, 
gravy, and sour bread,—all cold,—in quantity sufficient 
for a trench-digger. I have seen going out from the hands 
of a teacher of nurses in a diet-kitchen soggy Lyonnaise 
potatoes, lemon-pie with a soaked under crust, and 
burned toast—all on one tray. I have known of mince- 
pie being offered to a patient still in bed with pneumonia. 
In fact, I do not know of a hospital in the country from 
which I could not bring similar instances. If the cooking 
is good, the serving is bad; every evidence of total lack 
of appreciation of the office of food, of the best means for 
securing the fulfilment of that office; lack of codperation 
of all departments toward this end.” 

Little real improvement can be expected where such 
conditions exist until the kitchen is regarded more as a 
scientific laboratory, from which is to be supplied the 
substances needed to repair the waste, to renew strength, 
to assist the body in resisting the inroads of disease, until 
more value is placed on ordinary food as a remedial 
agent, and until superintendents of hospitals and training- 
schools and boards of managers realize their responsi- 
bility and their shortcomings in this respect, and work 
together to bring about a better state of affairs. 


meee GonrinG DEE TEE ECS 87 


The cost of a well-conducted dietetic department is 
urged against it. Nothing worth having is secured with- 
out some cost. Unless it is arranged that the materials 
used in teaching are used to supplement the meals, or 
that the nurses get their actual practice by assuming a 
certain responsibility for a part of the hospital dietary, 
this objection might be considered legitimate. It cer- 
tainly costs no more to cook a steak properly than to scorch 
it or otherwise spoil it, and this is true of the cookery of 
all foods. If the nurses know, and the doctors know that 
they know, how to prepare simple foods, such as milk, 
beef, and eggs, so that they are suitable for certain con- 
ditions, less of the predigested foods, beef-extracts, and 
such articles issuing from pharmaceutic laboratories— 
foods that are always costly—will be required. A recent 
writer (Dr. A. L. Goodman) in the “Dietetic and Hy- 
gienic Gazette” calls attention to the necessity of greater 
precision in the modification of milk for typhoid-fever 
patients, greater care in its administration, and a more 
careful study of the requirements of the individual. Where 
due attention is given to this one point, as the doctor has 
proved in his own hospital practice, there will be a pro- 
portionate reduction in the cost of other items, with equally 
successful results. Certainly the free use of such costly 
preparations or articles as panopepton, peptonoids, beef- 
extracts, and other similar pharmaceutic products, of 
grape-juice, orange-juice and albumin that is the rule in 
hospital work in recent years, has added immensely to 
the cost of caring for such patients. In these days of 
numerous and enormous hospital deficits these questions 
certainly require investigation. It may, however, be 
accepted as a fact that even should the placing of the 


88 TEACHING DIEDPE Wes 


hospital food department on a scientific basis, and the 
introduction of a sensible course of training in that branch, 
entail extra expense, the additional cost will be more than 
justified by the higher grade of service rendered. 

In planning for the practical instruction, arrangements 
differ widely. In a considerable number of hospitals 
the instruction is given by a paid teacher who comes to 
the hospital weekly. In others the dietitian goes from 
city to city, spending a term of two weeks or a month 
in a hospital, taking charge of special diets during that 
time, giving lectures and demonstrations, and instruct- 
ing the nurses how to conduct such a department. Usually 
after this course a nurse is placed in charge of the diet- 
kitchen and gives her time while there to the preparation 
of special diets and delicacies. In other institutions a 
trained dietitian is in charge of the diet-kitchen all the 
time, and nurses are detailed in turn for diet-kitchen work 
under her supervision. Whenever possible, it is well to 
have two nurses on duty in the diet-kitchen. With 
two-month terms, if nurses go from the diet work 
one at a time, it always leaves a senior diet nurse there, 
who understands ways and means and helps to keep the 
wheels running smoothly. In one large hospital having 
a very well-equipped dietetic department in charge 
of a graduate of Pratt Institute, four nurses are on 
duty constantly in the diet-kitchen, the terms being 
two months. With the exception of cereals and bread, 
the latter of which is bought already baked for the entire 
household, all food for the private patients is prepared in 
the diet-kitchen; also formulas for artificial food for infants, 
beef-juice, beef-tea, gelatin, custards, and semisolid diets, 
and special diets for ward patients. 


ion GH EN G DER EF PGs 89 


The work of the diet-kitchen is divided into four 
branches, each nurse being two weeks on each line of food. 
One prepares all meat and vegetables; another, ice-creams, 
salads, and desserts; another, special ward supplies and 
infants’ food; and the fourth attends to toast, broth, milk, 
butter, and anything that may be ordered not included in 
the other three divisions. All gluten bread for diabetic 
patients is made by the diet nurses. 

The food is sent by dumb-waiter to serving kitchens on 
the different floors. ‘Trays are set by the regular nurses. 
One nurse goes from the diet-kitchen to each floor and 
assists in serving it on the plates. The trays are carried 
to the rooms by the nurses on duty in those rooms. Ice- 
cream (and all ices) is dished in the diet-kitchen, and served 
to the patients separately, after the hot food is disposed of. 


CHAPTER IX 


Teaching Anatomy and Physiology 


\ 

How much of anatomy and physiology should a nurse 
know? How much time should be devoted to the study of 
this subject? What is the best way to teach it? ‘These 
are practical questions that have to be decided in every 
hospital training-school. One needs but to glance at the 
course of study as outlined in a half-dozen different train- 
ing-school announcements to see that a great diversity 
of opinion exists regarding at least the first two of these 
questions. The extent of instruction in these branches 
required in the ideal training of a nurse is a much-disputed 
question. In order properly to care for the disordered 
human machine, how much does a nurse need to know 
concerning the structure of its different. parts, their rela- 
tions and functions? Certainly a thorough education in 
these branches of science is unnecessary, and impossible, 
if other subjects be granted their rightful place in the curric- 
ulum. A nurse cannot know too much about the machine, 
the disorders of which are to furnish the demand for her 
services, but she can do good, practical work without going 
into the minutest details of the subject. 

This study is regarded as one of the foundation sciences 
in a nursing education, therefore the major part of the work 
in it must be done in the early part of the course. Just at 
that period in a nurse’s course there is need that she get 
instruction on a number of other subjects if she is to be 

90 


me OMY AND PHYSIOLOGY 91 


a trustworthy and intelligent nurse. ‘Therefore the ques- 
tion of amount of time that can be devoted to these studies 
is highly important. Before a nurse takes charge of a 
patient she ought to know something about foods—yes, 
a good deal about foods—the substances that must repair 
the waste of disease. She ought to know something about 
bacteriology if she is to prevent the spread of infection 
from one patient to another. She ought to know the 
principles of nursing and how to apply them in hourly 
practice. All these, at least, demand attention at the 
outset of a course, and none should be regarded as of 
paramount importance. Neither should they be slighted if 
the foundation for a nursing education is to be properly laid. 

In planning the course on anatomy and physiology it is 
customary in some schools to devote the opening lecture 
toembryology. Some catalogues announce an introduction 
dealing first with the general structure of the human body, 
and then take up the structural elements of tissues, the 
cell, ete. While at first glance this seems a rational 
method of beginning the study of the subject, a little 
thought, and, better still, a little experience, shows that 
there are disadvantages in that method. The average girl 
who enters a nurses’ school does not come fresh from school 
or college. As a rule, a few years, at least, have passed 
in which she has done little or no real study, and her mental 
processes are slower than when habits of study are well 
established. It is difficult, if not impossible, to teach 
embryology without the introduction -of a great many 
words difficult to distinguish, and remember, and under- 
stand, and such a lecture at the beginning is apt to be 
decidedly confusing and discouraging. It is questionable 
whether any school of nursing is justified in requiring its 


92 ANATOMY AND PHYSTODViGe 


pupils to study embryology. After ten years’ practice of 
nursing, there are comparatively few, if any, nurses who 
can point to a circumstance in which the matter contained 
in their lectures on embryology was of the least practical 
value to them. If a nurse wants to study embryology, 
or even astrology, let her do so, but why require it or waste 
time on it in the training period? If the time of the first 
lecture is devoted to the study of the general outline of the 
human body and the systems of the body, with a skeleton 
and charts for illustration and object-teaching, it will be 
found an easier road to knowledge. First let the thought 
of the human body as a whole be grasped, and its general 
structure understood, and the facts about the minute 
anatomy of tissue which a nurse needs to know will be 
decidedly easier of comprehension. ‘Begin with the 
known and proceed to the unknown” by the easiest steps 
possible is a good rule to bear in mind. 

In dealing with the systems of the body it seems best 
always to begin with the bony system, the framework 
which supports and protects the softer structures. The 
muscular system naturally follows next. The order in 
which the other chief systems of the body shall be taught 
is a matter of choice. The following arrangement seems 
as good as any: 

1. The osseous or bony system. 

. The muscular system. 

. The circulatory system. 
The respiratory system. 
. The digestive system. 
The absorptive system. 
The excretory system. 

. The nervous system. 


ONAA PR wh 


ANATOMY AND PHYSIOLOGY 98 


Then the study of the organs of the thorax and abdomen, 
their relative position and functions, might follow, and 
then the process of waste and repair, the chemistry of the 
body and the cell be taken up. If a nurse got no more of 
anatomy and physiology than this, taught in an elementary 
manner, she would have a fair working knowledge of the 
subject. And this is as much perhaps as it is desirable to 
try to put into the first year, if due proportion in time for 
the different studies is to be maintained. In the second 
and third years lectures on diseases are usually arranged, 
and it is a distinct advantage in studying the diseases of 
various organs to have as a preface the study of the anatomy 
and physiology of the part. 

Practically every lecturer in gynecology and obstetrics 
begins the course with a study of the female pelvis and gen- 
erative organs, their functions and their relative positions. 
Practically every lecturer on diseases of the eye begins 
with the study of the eye in health. The same rule applies 
to the study of nervous diseases, diseases of the digestive 
system, the respiratory and other systems. By arranging 
for this to be done, the cramming that must result if an 
attempt is made to crowd the whole subject into the first 
year is prevented, the nurse gets the broad outline of the 
subject as a foundation-stone at the beginning, and the 
more detailed study of the organs in connection with dis- 
eases comes at a time when she is better able to digest it. 

So much for the arrangement of the course. In the 
real teaching the best results will follow if lecture and text- 
book are combined. ‘To depend on the lecture method 
alone is folly, and it will be found that the student cannot 
do good work if dependent on the text-book alone. 
Salient points need to be emphasized. A carefully arranged 


94 ANATOMY AND PHYSIOLOGY 


syllabus of each lecture, with proper subordination of 
topics written upon the blackboard, helps to get the student 
into methodic habits of thinking and study. 

Anything that can be used by way of demonstration 
helps to hold the interest and to fix what is taught. A 
skeleton is an invaluable help, and a good anatomic chart 
showing the size, location, and relative position of the organs 
is a positive necessity to intelligent work. Wet specimens 
of the various parts can often be obtained, and if an autopsy 
can be arranged for, it will make many points clearer, 
especially if the lecturer knows how to utilize the teaching 
opportunity to the fullest extent. 

A well-directed quiz at intervals serves a useful purpose 
in the teaching of this subject. It helps the student to 
get his knowledge of the subject organized; it stimulates 
thought and is a distinct help to him in digesting and assim- 
* jlating what he has been taught. } 

The amount of time that needs to be devoted to these 
subjects depends very much on who is to do the teaching. 
Some teachers, by systematic planning and arrangement 
of a lecture, by knowing what they are going to teach and 
how to teach it, can get as much real substance into one 
lecture or class as another would in three. 'That question 
cannot be answered for any school without a knowledge 
of who is to do the teaching and how it is to be done. 

A few years ago no one dreamed of any one but a physi- 
cian teaching anatomy and physiology to nurses; and, 
providing the right physician can be found, he ought to 
be in a better position to do such work efficiently than any 
nurse. But “there’s the rub!”—“providing the right 
physician can be found!” The old fallacy that every 
physician has a proper conception of what a nurse needs 


PNA TOMY AND PHYSTOLOGY 95 


to know, and is, by virtue of his medical training, fitted 
to teach nurses, dies hard. Quite recently a company of 
physicians met and solemnly resolved as follows, and some 
of the leading medical journals evidently entirely agreed 
with the sentiments of the resolutions: ‘‘ The professional ’ 
instruction of orderlies and nurses should be intrusted 
exclusively to the physicians, who only can judge what is 
necessary for them to know. The physicians charged 
with this instruction should never forget in the course of 
their lectures to insist on the possible dangers of the initia- 
tive on the part of orderly and nurse, and on the serious 
responsibility that would be incurred in case of accident 
by the persons thus inconsiderately stepping out from their 
proper sphere.” 

Theories are beautiful things when they will work. 
Usually they make interesting reading, and such resolu- 
tions will not do any one serious harm. There is, how- 
ever, nothing like real, genuine, every-day experience to 
help one to get rid of false conceptions. For years the 
author held to the theory that anatomy and physiology 
should be taught only by physicians, and that such in- 
struction should come early in the nurse’s course if a sub- 
stantial foundation for a nursing education was to be laid. 
In order to find out just how firmly this foundation was 
being laid in her own school by the physicians who were 
lecturing to her nurses a careful scrutiny of the nurses’ 
lecture notes was made. She had timidly and respectfully 
suggested to the physician an outline of the course in 
anatomy, what she thought the nurses should be taught, 
and mentioned that the pupils were supplied with Kim- 
ber’s text-book, which she would like used. She was in- 
formed by the physician, in lofty tones, that he would rec- 


9% ANATOMY AND PHYSTORGee 


ognize but one text-book on anatomy,—Gray’s,—and the 
lectures proceeded. ‘The notes of the first lecture, taken 
by one of her brightest nurses, read as follows: 

“Anatomy—Cranium, complicated affair, contains 
brains embryo. Neural canal 1 in. in length, epiglastic 
membrane on either side. Rolls upon itself, dome of head 
is composed of membraneous tissue, also cartilage. Seph- 
alic skull proper; vault by membrane base—cartil—Indian 
triangular dark skin globular skull has four centers and 
panetal—outer and inner—softer—harder separated by 
one-quarter inch cellular tissue. Tetal skull—at junction 
sagital—fontanelle anterior and posterior—oval and long 
—open to years. R. F. closes sixth week new-born babe 
—pulse in anterior font—nucleus center of bone. Skull 
protection—ear to middle of head one-half inch back of— 
middle fissure of sylvius muddle inguinal artery. 

“Legs, arms, face, heart, lowest middle inversely to 
parts they supply. Brain seldom injured by external— 
fracture at base—1 inch cebal fluid brain floats—circula- 
tion of brain and skull, 2 vertebree unite divide into poster. 
cerebral arteries either side of brain. Circle of Willis. 
Blood-vessels pass off dead portion of brain. 

“Two centers for sight in cerebrum. Nerve-fibers pass 
to each eye, right to left, left to right. Individual—both— 
or all to one eye.” 

The remainder of the lecture was on the same order. 
What foundation is such teaching for a nursing education ? 
What good does it accomplish? ‘This is by no means an 
extreme illustration. It is quite likely that an examination 
of nurses’ note-books in hundreds of hospitals would 
reveal similar conditions. A later experiment was made 
with another physician as a teacher on anatomy and physi- 


ANATOMY AND PHYSIOLOGY 97 


ology. A careful outline of the course was prepared—in 
short, the outline that appears in the course shown in 
previous pages. ‘The number of class hours that could be 
devoted to anatomy during the first year was stated. When 
the time allotted had nearly expired, it was found that only 
three or four of the prescribed lectures had been given, 
and the nurses were getting up at three or four o’clock in 
the morning to make excursions through Gray’s, and ago- 
nize, when they found them, over the names and origin 
of all the muscles in the body. What possible use can it 
be to the average nurse to study about the pterygoman- 
dibular raphé, the mylohyoid, the levator palpebre, the 
orbicularis oculi, or a hundred other portions of the human 
organism? If she is going to specialize as a masseuse or 
a director of medical gymnastics, perhaps she needs this 
knowledge. If she does, she needs a great deal more train- 
ing along these lines than the average hospital training- 
school is prepared to provide, or than is possible for her 
to benefit by, in the limited time allowed and with the 
multiplicity of subjects that are demanding her attention 
as an undergraduate. She needs thorough postgraduate 
instruction, and months of uninterrupted time and study, 
in order to become a really efficient specialist in these 
branches. 

Is it any wonder that nurses leave hospitals without 
ambition for study after the style of teaching shown as 
examples? Is it really teaching at all? If we accept the 
definition that “Teaching is causing another to know,”’— 
to know what the teacher knows,—then it surely can hardly 
be classed as teaching by any impartial judge. Is it any 
wonder that many superintendents of hospitals and nurses, 


in the interests of nursing and of the prevention of cruelty 
7 


98 ANATOMY AND PHYS LOC Ges 


to pupil nurses, have been driven to “‘inconsiderately step 
out from their proper sphere” to courageously take the 
teaching of anatomy out of the hands of physicians, and 
either teach it themselves, or intrust it to a head nurse 
who had some conception of the parts of the great subject 
that nurses needed to know in order to become efficient 
practical nurses. 

Most of the text-books on anatomy prepared for nurses 
contain altogether too much. A teacher of nursing writing 
on this subject recently made this comment: “There are 
only about a dozen muscles mentioned in nursing practice 
in any practical way, about fifteen arteries, about six 
nerves.” After examining about a dozen text-books pre- 
pared for nurses, and presumably adapted for their use, 
the author has made choice of Furneaux’s “Human Physi- 
ology” as the most simple, clear, concise presentation of 
the subject that has come to her notice. A few chapters 
may need to be elaborated somewhat, but it is much easier 
to elaborate, to have pupils interleave their text-books 
and add a few important points, than to wander through 
scores of tedious pages, to cull out the essential facts that 
will help them in actual practice. If a nurse has mastered 
the contents of that little volume, she ought to be able to 
pass any fair, reasonable examination on that subject. 
There will frequently come up points not contained in it, of 
course, but that is true of any incomplete presentation of 
any subject. Complete text-books on the various subjects 
allied to nursing should be in every training-school library 
for reference. 


CHAPTER X 


Teaching Practical Nursing 


The instruction of the nurses in correct methods of prac- 
tical nursing is by far the most important part of the course. 
It is true that “we learn to do by doing,” but if uniformity, 
and correctness, and exactness in nursing are desired, 
the nurses must be shown how these are to be secured. 
Those who have tried it for years have concluded that one 
of the most valuable methods yet discovered for the teach- 
ing of practical nursing is by clinical demonstrations before 
the whole class. 

There are few lines of instruction in methods in which 
clinical demonstration may not be used with advantage 
if the superintendent of nurses is sufficiently interested in 
teaching to plan forit. If she has not a genuine conviction 
of its value, if she is not willing to plan for it and think it 
out carefully, it will not be adopted in any training-school. 
Such things do not happen. It is manifestly impossible for 
a busy superintendent to give thorough personal instruction 
to each individual nurse as to the methods she wishes the 
nurse to use, and if her methods are left to be handed down 
through the uncertainties of tradition from class to class, 
or through head nurses, she herself would not recognize 
them often after a few years, and she may find no two 
nurses doing things in the same way. ‘Therefore, if she 


wishes her methods to be the methods of her nurses, she 
99 


100 PRACTICAL NURSING 


herself must show them to the nurses, and it must be 
done in classes. 

Just how much instruction should be arranged to be given 
to probationers by clinical demonstration depends on 
the kind of work the nurse is to be given to do in the first 
year, how much teaching she will get without it, and how 
much responsibility will be placed upon her. That is a 
point in which every hospital is a law unto itself. The end 
and aim of all education is to fit people for the responsi- 
bilities of life and the work they will have to do, and that 
is precisely the end and aim of clinical instruction—to fit 
the nurse to do properly the various duties she will be ex- 
pected to do when she is given nursing responsibility. 
It is a pretty safe rule to adopt that no nurse will be per- 
mitted to do any duty for a patient until she has first been 
shown the correct method of doing it, and understands 
the reason for doing things that way. It is a protection 
to the nurse, to the patient, and to the hospital. 

The clinical demonstrations for the probation period 
might be divided as follows: 

1. Beds, bedding, bed-making with or without a patient, 
management of helpless patients, changing beds, bed- 
making for operative patients. 

2. Sweeping, dusting, preparing a room just vacated 
for reception of a new patient, disinfection of bedding, 
furniture; preparation for fumigation; care of patients’ 
clothing in ward and private rooms; care of linen rooms, 
bath-rooms, and appliances that are kept in bath-rooms. 

3. Baths—full, sponge, to reduce temperature; packs, 
half packs, foot-baths, vapor baths, hot-air; care of hair, 
mouth, teeth; babies’ bath. 

4, Administration of enemata for laxative, nutritive, 


PRACTICAL NURSING 101 


stimulant, astringent purposes; colonic flushing; prepara- 
tion of fluids; care of appliances. 

5. Gynecologic positions, gynecologic examinations, 
instrumental and non-instrumental, how to prepare for 
them; vaginal douches; methods of preparing appliances. 

6. Local application of heat and cold, care of ice-caps 
and coils, care of hot-water bottles; counterirritation; in- 
unction; bladder irrigation; uses and care of catheters; 
lavage. 

7. Administration of medicine and preparation of solu- 
tions. 

8. Preparation for and management of ward dressings, 
sterilization, care of dressings and appliances. 

9. Temperature-taking, chart-keeping, methods of re- 
cording bedside observations, taking orders. 

10. Making of bandages—roller, many-tailed, plaster, 
eye, abdominal, breast, and T; some methods of applying 
bandages and removing them. 

11. Bacteriologic demonstration; methods and _ tests 
of disinfection and fumigation; cultures of different dis- 
ease germs; conditions favorable to development; pre- 
ventive measures. 

12. Tray-setting; administration of food to delirious, 
helpless, and other patients; artificial feeding of infants; 
care of bottles and food. 


BED-MAKING 
For the lesson in bed-making an unoccupied room may 
be used for the demonstration if the class be small or the 
operating theater if the class be large. Before the lesson 
a carefully arranged plan must be made, so that the lesson 


102 PRACTICAL NURSES 


may proceed in regular order and all important points be 
included. If possible, an assistant should be arranged for, 
who will demonstrate while the superintendent lectures and 
explains. If a head nurse is not available to assist in this 
way, a senior pupil nurse could be pressed into service, 
and if, in years to come, she herself must manage the clin- 
ical demonstrations for her own pupils, she will find that 
bit of experience valuable indeed. 

The hospital bed, the difference between it and ordinary 
beds; reasons why iron beds are preferred; methods of 
cleansing and of exterminating vermin; mattresses of all 
kinds, why some are preferred to others; protection of 
mattresses and pillows for certain cases; bedding—these 
and various other points may form the introductory talk. 
The bed may be made without a patient, the proper 
methods being explained at each step; then the bed may 
be made and changed with a patient, showing the proper 
way to change upper and lower sheets, pillow-covers, turn- 
ing helpless patients, and special precautions to be used 
in cases of typhoid fever, abdominal operative, or accident 
patients, adjustment of back-rests, air-cushions—substi- 
tutes for these when hospital appliances are not to be had. 
One lesson that may be given here and repeated at frequent 
intervals all through the nurse’s course is “it is practically 
never necessary to completely uncover any patient.” ‘This 
is one lesson a nurse can never learn too early nor too 
thoroughly. The making of a bed for an operative patient, 
with the other preparations a nurse would be expected 
to make for a patient coming from the operating-room, 
should form a part of this lesson also. Very plain instruc- 
tion as to the temperature of water in hot-water bottles 
for such a bed may save embarrassment later on. Other 


PRACTICAL NURSING 103 


points will suggest themselves to those who are preparing 
to give these demonstrations, and a trial will convince any 
who are skeptical as to the value of this means to secure 
that uniformity of methods that is essential in a well-con- 
ducted hospital. 


SANITATION 


A second demonstration of methods might well be de- 
voted to sweeping, dusting, preparing a room just vacated 
for the reception of a new patient, disinfection of bedding, 
furniture, etc., preparation for fumigation, care of pa- 
tients’ clothing in ward and private rooms, listing cloth- 
ing, etc., care of linen rooms, bath-rooms, and appliances 
that are kept in bath-rooms. 

There is a great difference of opinion about whether or 
not nurses should be expected to sweep and dust. One 
doctor writes in a medical journal or complains to a hos- 
pital superintendent about the graduate nurse who would 
not keep her patient’s room in order, and who expected 
the maid to bring up the patient’s meals and remove the 
tray, and demanded waiting on generally. Another doctor 
writes a vigorous protest against nurses having to sweep 
and dust and do the work of a maid, and leave undone 
attentions that ought to have been given to patients. 
And there is just as much difference in the minds of super- 
intendents of hospitals and nurses about the nurse’s legit- 
imate work, and what she ought to be expected to do. 
There is a great deal to be said on both sides, and the last 
word on the subject will not be said in our generation. 
The question will be settled in each hospital in the way 
that the superintendent and superintendent of nurses, and 
authorities in general of that hospital, believe to be best 


104 PRACTICAL NU RSG 


for that hospital and for their nurses. But this point must 
be admitted, that if the superintendent of nurses wants 
thoroughness and uniformity and method along the lines 
mentioned, she must demonstrate in some way what she 
understands by thoroughness. Her ideas of thoroughness 
and the probationer’s ideas of thoroughness will be likely 
to be decidedly at variance on some of the points. ‘There 
is not a superintendent who has not at some time had reason 
to reproach herself for taking for granted that the proba- 
tioner knew a great many things that she did not know. 
The only way to be absolutely sure that a probationer knows 
any of the essentials of proper ward work is to teach those 
essentials. ‘The wise, experienced superintendent no longer 
takes it for granted that a probationer, of course, knows 
even how to make as simple a thing as a cup of tea or a 
piece of toast, or dust a ward properly. In spite of pro- 
tests there are those—not a small number either—who 
believe that the lines of work mentioned are a part of a 
nurse’s legitimate work in the hospital and out of it, and 
who are living up to their beliefs, and teaching as carefully 
about sweeping, and dusting, and fumigating, and dis- 
infecting bath-room appliances as they teach operating- 
room technic or materia medica. There are a great many 
who believe that habits of thinking have a great deal to 
do with nurse’s conduct in private practice. And if a nurse 
is started out in the hospital with the idea that the keeping 
of the ward in a hygienic condition is menial work, suitable 
only for ward maids, she gets habits of thinking started 
that will stick to her when she gets out in practice and lead 
to trouble in the families to which she is called. And it 
will be generally conceded that a nurse ought to know how 
to do all these things properly, even if she always has a 


pew LrLCAL NURSING 105 


maid at her side to do the actual work. ‘Therefore a clin- 
ical demonstration of methods to be used in the daily per- 
formance of these duties is a necessity if the superin- 
tendent expects thoroughness. 

Even though we bar air-borne diseases out of the ward, 
we cannot bar dust out, and the germs of any disease, 
typhoid fever, pus, or any of the common diseases may 
become dry and by means of dust in the atmosphere settle 
down on the food on a patient’s tray, and transmit disease 
to one in a weakened condition. 


CARE OF ROOMS 

Such a clinical demonstration might be begun in a room 
which had just been vacated. The care of the rugs, the 
proper mode of sweeping, the disinfection and care of the 
mattress and furniture, an explanation of the patient’s 
clothing book and the nurse’s responsibilities regarding 
his clothing, the preparation of the room, and the methods 
used in fumigation in that hospital could be taught there 
by practical demonstration. ‘Then the class might repair 
to the linen room and be taught to place on the shelves, 
in their proper order, the clean linen just sent from the 
laundry. ‘The bad habits of nurses who pull a sheet from 
the bottom of a pile, and upset it and leave it in that con- 
dition, and a dozen other annoyances that have to be com- 
bated in the efforts to keep the hospital linen closets in 
respectable order, may be dwelt on and warnings as to 
what not to do given. 

In the bath-rooms and nurses’ service rooms, where 
frequently are kept the douche cans and pans, bed-pans, 
urinals, nozzles, sputum cups, a splendid opportunity 


106 PRACTICAL NU RSs 


1s afforded for teaching proper methods of disin- 
fection and cleansing, care of plumbing, and bath-room 
cleanliness. Call it a demonstration of hygienic methods, 
or anything else that you like, but teach it somehow and 
teach it thoroughly. If there is one thing considered 
inexcusable in a hospital it is dirt, and absence of dirt never 
happens by accident. Nor can the nurse be taught too 
soon the proper methods to be used in the warfare with 
dirt, and especially the kind of dirt found in hospital 
bath-rooms. 

The outline of a course of lectures to nurses on “Hy- 
giene,”’ to be given in a certain hospital, reads as follows: 

“Water: composition, sources of impurity. Air: com- 
position, varieties in composition produced by altitude, 
moisture, ventilation, effects of impure air, air space, tem- 
perature.” 

Not a word about personal hygiene, not a word about the 
way to keep a hospital ward and bath-room in a hygienic 
condition. ‘There is a text of scripture which says some- 
thing like this: “These ought you to have done and not to 
leave the other undone.” That text may be applied to the 
outline of that course on ‘“ Hygiene.” 

It probably will never do a nurse any harm to know 
the variations in the composition of air that are produced 
by altitude, but she probably will never have to decide 
the question as to whether a high altitude or a low one 
should be sought in any disease, and the same may be said 
about the water-supply. These are questions that will be 
settled by other people. The nurse’s opinion on the sub- 
ject will not likely be asked. But it may do her a great 
deal of harm, and the patients in a hospital ward and out 
of it, if she does not know how to keep toilet utensils clean 


Pewee CAL NURSING 107 


or make a room just vacated safe and respectable for the 
reception of a new patient. 


ENEMATA 

When it comes to teaching about enemata by clinical 
demonstration, one might at first glance suppose that while 
there was a good deal to be taught, there was not much to 
be demonstrated. The whole subject ought to be taken 
up in class and the theories thoroughly explained before 
attempting a demonstration. Indeed, that rule should 
be applied to all clinical demonstrations. They should 
not be attempted as a simple mechanic process, but as an 
illustration of what has previously been taught by lecture 
and recitation. To begin to demonstrate how to give a 
colonic flushing when the nurse had but the vaguest idea 
of what a colonic flushing was, or even that “colonic” 
had anything to do with “colon,” would be equal to putting 
the cart before the horse. Such a demonstration might 
be given in an ordinary class-room—the first part of the 
lecture, at least. The different appliances used in giving 
rectal injections should be collected and exhibited. The 
reason for preferring one kind of syringe to the other in 
certain injections, and the reason for never using some 
kinds of syringes that are on the market unless nothing else 
is to be had, should be clearly shown. The Davidson 
syringe may very properly be condemned and retired from 
active service in a hospital, but unless a nurse has been 
told the reason for discontinuing its use she may fail of 
good results later if she tries to use it in a private home 
where it so frequently forms part of the equipment for 
dealing with sickness. In using a Davidson syringe for 


108 PRACTICAL NU Ree 


injecting a small amount of fluid into the bowel it is almost 
impossible to prevent air being drawn into the syringe with 
the enema. When a nutrient enema is thus administered, 
the effect of the air is to excite peristalsis and cause evacua- 
tion of the bowel, and the same objections to the use of a 
funnel in such work may be urged. ‘Thus, by using im- 
proper appliances, a nurse may very easily defeat the object 
of the treatment. 

So many points enter into the successful administration 
of enemata, and such important results are dependent upon 
their skilful administration, that too much pains cannot be 
taken to teach thoroughly and clearly the exact points to 
be observed in giving the different classes of enemata. 
Even the lubricant used for the rectal tube may influence 
the result of an enema. It is well known that glycerin 
excites peristalsis, and while it might be perfectly admis- 
sible to use it in giving a laxative enema, it ought never to 
be used in giving a nutrient enema. The position of the 
patient, the way to elevate the hips, the aids to retention, 
the quantity, the temperature, the preparation before giving 
an enema that is expected to be retained, the length of tube 
to be passed in high injections, the preparation of a simple 
soap-suds enema, a starch enema with laudanum, the small 
special enema now so often used in surgical cases, consisting 
of salts, glycerin, etc., and the preparation and administra- 
tion of a nutrient enema which has been preceded by a 
laxative enema, with the appliances to be used in the hos- 
pital for those purposes, will make a valuable lesson to the 
nurse. It will save the superintendent much future annoy- 
ance—the exasperating kind of annoyance that comes from 
blunders and from taking things for granted. It will not 
prevent all blunders and failures in the administration of 


pee eC PtrCAL NURSING 109 


enemata, but it will lessen the number. In general it will 
be found that a hard-rubber syringe holding about four 
ounces attached to a rectal tube is a good appliance to keep 
on hand for the giving of nutrient enemata. 

An important part of this and all lessons is the care of 
appliances before using, immediately after using, and the 
teaching of the place in which they are to be kept when not 
in use. A nurse cannot be too thoroughly impressed with 
the importance of these duties, which mean the difference 
between order and disorder in a hospital. 

In connection with the lesson on enemata it is wise to have 
samples of suppositories on hand, to tell for what purposes 
they are used, and to give one before the class. The 
need of this practical teaching about suppositories was 
forcibly demonstrated in a certain hospital. The young 
superintendent had not learned the value of practical teach- 
ing, and had passed over the subject of suppositories in 
class with a casual mention of their uses. One nurse at 
least, in the class, had never seen a suppository, and had 
but a very vague idea of what the thing was. It so hap- 
pened that a year or more passed before she was ordered 
to give a suppository, and before that time all that teacher 
and text-book had said about the things had passed from 
her mind. If the teacher had shown a suppository and 
had given one before the class, she would have been likely 
to remember what she saw. The suppository was sent 
to her to give, and the superintendent, to her dismay and 
humiliation, learned afterward that the nurse had taken the 
suppository to the patient in a teaspoon ona little tray 
with a glass of water and tried to make the patient swallow 
it. The nurse who did that is married now, and out of 
active practice as a nurse, but from stories heard there are 


110 PRACTICAL NURSING 


nurses still in hospitals and elsewhere who have made pre- 
cisely the same blunder. ‘The remedy for that kind of 
blunder is thoroughness in teaching and the practical 
demonstration, so far as possible, of the methods to be used. 


THE ADMINISTRATION OF MEDICINE 


A demonstration of methods of administration of med- 
icine is rather more difficult to plan for than some other 
demonstrations, but it can be done and it is just as much 
needed as practical instruction along other lines. As in 
other subjects, the theory should be taught before attempt- 
ing to demonstrate methods. ‘There are at least five or six 
methods by which medicines may be given, each method 
requiring a different apparatus, which may be shown. 
Each hospital has its own way of making out medicine 
lists and getting out medicines, which need to be explained. 
Even in the simple matter of pouring out a dose of medi- 
cine and carrying it to a patient a nurse will show whether 
or not she has been well trained. 

Such a demonstration may commence with an exhibition 
of specimens of ordinary medicines in their various forms— 
pills, tablets, capsules, powders, oils, plasters, liquids, oint- 
ments, etc.—and also the various appliances and vessels 
used in measuring or administering medicine. ‘These 
would include medicine-droppers, minim glasses, graduate 
glasses, large and small, atomizers, inhalers, hypodermic 
syringes, antitoxin syringes. It would be well also to show 
how appliances for the inhalation of steam or medicinal 
vapor may be arranged and improvised, also the proper 
method of using the nasal douche, eye-bath, eye-drops, 
and ear irrigations. 


PRACTICAL NURSING 111 


The method of preparing a hypodermic injection, and 
preparing the part for it, as well as the method of giving it, 
should be shown, and what is fully as important, the proper 
way to take’care of the hypodermic syringe and needle 
when not in use. The superintendent who teaches this 
lesson thoroughly may then be sure that every nurse knows 
better than to leave needles without wires, and syringes to 
dry up, so that when a syringe is needed in a hurry, both 
syringe and needle are of no value. The proper method 
of caring for medicine-droppers, atomizers, and such 
things, and the place in which they are expected to be kept, 
together with the care of medicine cupboards, a listing of 
the medicines that must not be kept in a warm place, others 
that will deteriorate if kept in the light, may be introduced 
into this lesson with profit. 

This kind of teaching for nurses will be the means of 
saving expense in ways that are perhaps not dreamed of 
at the time. The nurse who has thus been carefully in- 
structed will not be likely to make the blunder a nurse 
superintendent made not long since. She had the car- 
penter arrange a set of shelving against a chimney in the 
drug-room, and gave instructions to have placed thereon 
large stock-bottles of a number of different preparations, 
also the entire stock of suppositories. ‘To her great dismay 
she found soon after that most of the drugs had deteriorated 
so as to be unfit for use, because of being placed against 
the chimney, and the suppositories had melted. 

Unless a superintendent wants her nurses to carry pills 
and tablets in their fingers and a glass of water in the other 
hand she will need to show them a better way. The best 
way to give medicine to delirious or insane patients should 
be shown, and also how to give medicine to a baby. ‘The 


112 PRACTICAL NU RSS 


way to prepare chloroform and ether inhalers may also 
come in this lesson. 

Either in this lesson or in the teaching of materia medica 
specimens of crude drugs may be shown. ‘This demon- 
stration may properly conclude with a lesson on the prepara- 
tion of solutions and the care to be exercised in handling 
them. A few questions in the arithmetic of medicine, 
working out percentages, calculating doses, ought to come 
in somewhere. ‘There is no better way to make sure that 
a nurse will not make the blunder that some nurses have 
made of giving two one-fiftieth grain tablets of nitroglycerin 
when they were ordered to give one one-hundredth of a 
grain or two one-thirtieth grains of strychnin when they 
were ordered to give one-sixtieth of a grain, and the tablet 
with the exact amount ordered was not in sight. Exact- 
ness in nursing costs. It is never secured without a 
large expenditure of brain work and time and energy. But 
no one ought to undertake the business of teaching nurses 
who is not willing to pay the price needed to secure it. 


BATHS 

In no part of nursing is careful teaching of practical 
methods more important than in the giving of baths. ‘To 
send a nurse, without instruction, to give a bath of any 
kind to a patient is a grave injustice to both patient and 
nurse. The very first duty a probationer was given to do 
in a certain hospital was to sponge a typhoid-fever patient 
to reduce temperature. She had never seen a fever patient 
before, knew absolutely nothing about the disease, the 
precautions to be used, or of how to sponge for any pur- 
pose. That happened some years ago, but there is 


PRACTICAL NURSING 113 


every reason to believe that, today, the practice of thrust- 
ing such duties upon nurses without previous instruction 
and demonstration of methods is carried on in a large 
number of hospitals. An orderly who was employed in 
a hospital of 300 beds, in applying for a position in another 
institution, stated that he “ knew how to give all kinds of 
baths, and often had to teach the new nurses how to gwe 
them.” He said that, just the night before, a nurse was 
put on night duty for the first time. Orders were given to 
her to apply cold packs to two typhoid-fever patients. She 
had never seen a pack applied, had no idea of how to go 
about it, and came to him to show her how. He had had 
eight years of ward work, and, of course, had learned a 
good deal regarding practical methods. Knowing some- 
thing of the reputation for veracity of the average orderly, 
and believing that this one surely must have been exagger- 
ating or coloring the facts, a careful inquiry was made of 
others who were in position to know the truth. From 
other facts learned regarding the methods of instruction 
in that institution and others there is every reason to believe 
that some nurses are still left, in a great many hospitals, 
to pick up methods from orderlies or ward maids, to evolve 
their own ways of doing things, or to learn by their blunders 
and at the expense of the patient. This may not be true 
of the majority of hospitals, but, unfortunately, it is true 
of some. 

Water is the only remedy that is found everywhere. It 
is applied to a wider range of diseases than any other rem- 
edy. It is a safer remedy than any other for a nurse to 
use in a great many emergencies which she will have to 
meet. In most cases its success as a remedial agent de- 


pends on attention to the minutest details. Whether it is 
8 


114 PRACTICAL NUEGiRSG 


used in the form of ice, or steam, or in its liquid state, 
whether it is applied hot or cold, its chances of suecess may 
easily be defeated by ignorant or careless management. 
And yet, in a great many schools, if one is to judge by their 
published announcements, not one lecture, not one class 
in theory, not one careful demonstration of how to apply 
this simple and powerful remedy, is given in an entire three 
years’ course. ‘The neglect of this branch in many nursing 
schools is hard to understand until one brings himself to 
realize that the very same neglect is found in many schools 
of medicine. 

If water is to be applied intelligently and the best re- 
sults are to be produced, systematic and careful instruction, 
accompanied by demonstration of correct methods, should 
certainly be given. ‘The nurses should understand some- 
thing of the physiologic effects of external and internal 
applications of water, when it should and should not be 
used. It is well known that effects vary according to the 
mode of application, the duration of the treatment, the 
temperature of the water used, and also the temperature 
of the room in which the application is made. But there 
are a great many nurses sent out as graduates who could 
not state with any degree of confidence or accuracy the 
degrees of temperature at which a bath might be classed 
as cold, cool, tepid, warm, or hot. 

The technic of baths is certainly as important to the 
great majority of nurses as is surgical technic. Many 
nurses in private practice are not called to deal with one 
surgical case in a year. Most patients who need surgical 
operations go to hospitals, even if they are able to pay a 
nurse, but there are comparatively few medical cases in 
which the nurse will not have an opportunity to apply 
water as a remedial agent. 


ee 
Meee TT CAL NURS ENG 115 


In arranging for clinical demonstrations it is wise, as 
far as possible, to teach methods that can be carried out 
in a private house and without an expensive outfit. The 
right use of the appliances provided by the institution for 
giving scientific treatments will, of course, be included, 
but the other phase of the subject should not be neglected. 
Clinical demonstrations on the subject of baths may wisely 
begin with the correct method of giving a cleansing bath. 
Methods of sponging with and without friction, of applying 
the wet-sheet rub, the wet-sheet packs, hot and cold, the 
various forms of compresses, the half packs, the Scotch 
douche, the spinal sprays, the foot-bath, and all the variety 
of external applications will certainly mean very valuable 
lessons for every nurse. A few points will usually need 
emphasis—the need of avoiding unnecessary exposure, of 
saving the strength of the patient, the necessity of avoiding 
guessing or of trusting to the sensations, the need of using a 
bath thermometer to determine temperature, that the effects 
are not alone due to the water, but to the impressions of 
heat or cold produced by water when applied to the body. 

Regarding the internal uses of water, such as in lavage, 
irrigations, enteroclysis, saline injections, hypodermoclysis, 
etc., there will be no difficulty in securing opportunity for 
practical teaching. After showing to the class the different 
appliances and explaining their uses, how to prepare them 
for use and care for them afterward, it will usually be better 
to take small groups of nurses, when such treatments re- 
quire to be given, and instruct them in the art. In plan- 
ning such instruction for her own classes the author has 
depended largely on Kellogg’s “Rational Hydrotherapy.” 
A study of the illustrations in that volume cannot but prove 
of very great assistance in arranging for such clinical de- 
monstrations. 


CHAPTER XI 


Teaching how to Observe Symptoms 


The criticism has been made of nurses that though they 
have better opportunities than are afforded any one else 
of continuous observation of the manifestations of disease, 
yet they have added nothing to the sum of human knowl- 
edge of the subject. Those who are familiar with the 
situation know how easy it is for nurses to get into per- 
functory habits of bedside observation and recording— 
how much more they might see than they do; at least, this 
is true of the majority. 

If this condition is not forever to exist, more attention 
will need to be paid to teaching them what and how to 
observe. In most text-books there are instructions regard- 
ing points to notice. ‘This theory should be taught early 
in the course, but the best teaching of symptoms will be 
that which is done day by day, at the bedside, by physicians 
and head nurses. 

A progressive physician has said, “There is no ‘doubt 
in my mind that there are many facts about disease which 
will never be noticed at all, and so never become part of 
our working knowledge unless nurses have the energy and 
persistence to record them and bring them before our atten- 
tion.* Under his direction the nurses of a certain hospital 
were induced to make a special study of vomiting. Inas- 
much as a nurse has fifty chances to see the act of vomiting, 


* Dr. Richard Cabot, in ‘“‘The Trained Nurse.” 
116 


GEaseERVING SYMPTOMS 117 


to observe the symptoms that preceded and followed it, to 
one chance that a physician has, it was hoped that by 
directing special attention for a time to that one symptom 
facts might be learned that physicians had not before 
thought of. ‘The observations were to continue until 1000 
cases had been recorded. ‘These observations of this one 
symptom were then to be put together, classified, and 
arranged in statistic form. 

At the City Hospital, Worcester, Massachusetts, a very 
thorough and interesting clinical course on the observation 
of symptoms has been given by Dr. George E. Deering, 
Assistant Superintendent, an outline of which is introduced 
here, by permission of Dr. Deering, in the hope that it 
may prove suggestive to teachers of nurses. 


“OUTLINE OF CLINICAL COURSE 

“This course is intended to give the nurse a compre- 
hensive idea of how and why the doctor makes certain 
examinations, in order that she may be a more efficient 
and intelligent assistant, and to make her a better and 
more accurate observer by teaching her what she should 
observe, and giving her a definite and accurate idea of 
certain phenomena, the immediate and intelligent obser- 
vation of which not infrequently means so much to the 
patient. 

“A considerable number of more or less unimportant 
phenomena are introduced into the course as they present 
themselves, both to keep up interest and to bring into more 
marked contrast conditions of greater importance. 

“No attempt is made to teach diagnosis, the whole 
object being to make the nurse a better and more accurate 


118 OBSERVING SYMP DT Our 


observer, a quicker and more consistent thinker, and a 
more resourceful and efficient helper to the physician both 
in the hospital and in private nursing. 

“The class is divided into small sections, five or six 
pupil nurses in a section. One hour is allowed for each 
clinic. A talk of from five to ten minutes is given before 
the exercise, explaining the important points to be 
observed. Sufficient time for asking and answering 
questions and for discussion is allowed at the end of the 
hour. 

“The first five exercises are given in regular order, the 
object being not to teach the pupil to diagnose any of the 
diseases shown, but to increase her powers of observation. 

“These five exercises are on the circulatory and respir- 
atory systems. ‘Typical cases are always shown. 


“FIRST CLINIC-NORMAL CHEST 

““Two patients are used. 

““A regular routine examination is made by instructing, 
including— 

Inspection. 
Palpation. 
Percussion. 
Auscultation. 

“Each step is carefully explained, the nurses taking notes 
if they so desire. Each nurse repeats this examination 
herself and compares notes with the instructor. ‘The ob- 
ject of this clinic is to show the nurse what is normal, and 
to emphasize the necessity of quiet during examinations. 

“Proper positions are shown. 

“Draping patient for examination is taught at this exer- 
cise. 


OBSERVING SYMPTOMS 119 


“SECOND CLINIC—HEART-SOUNDS 

“Murmurs. 

“ Aortic and pulmonic second sounds. 

“This is a lesson in accuracy of observation. 

“The nurses in order (without instruction other than that 
given at first exercise) palpate the heart apex, count the 
ribs, and write on paper where they consider the apex 
to be. This paper is immediately handed to instructor, 
notes are compared, and each nurse individually shown the 
correct method. 

“Each nurse listens to one or more heart murmurs. 
No attempt at diagnosis is made. 

“ach nurse listens in the pulmonic and aortic areas, 
and writes on paper which sound is louder, handing same 
to instructor at once. No discussion is allowed until all 
have examined patient. Those in error are then shown 
the cause of wrong observation. 


“THIRD CLINIC—PULSE 

“This being one of the most important exercises in the 
course, considerable care is used in selecting cases, and as 
there are constantly upward of 200 patients in the house, 
there is no difficulty in illustrating the variations in quality, 
etc., on typical cases. 

“Each nurse palpates the radial, facial, temporal, 
carotid, dorsalis pedis, and brachial arteries in cases where 
the pulse is normal. 

“A case of arteriosclerosis is shown and the artery pal- 
pated, and cause of findings explained. 

“A tortuous artery is examined. 

“On suitable cases the following characteristics are 
illustrated, and terms are explained: 


120 OBSERVING SYMED Gis 


Volume. 
Tension. 

Rate. 

Rhythm. 
Quick. 
Dicrotie. 

Well sustained. 

“On other cases the nurses make the observations them- 
selves, committing themselves on paper, and when all 
have made the examination, are corrected if wrong. ‘The 
effect of fever in quickening and weakening the pulse is 
shown, and the increased tension in the two diseases, ne- 
phritis and arteriosclerosis, is illustrated. The irregular 
pulse of myocarditis and the irritable heart of certain 
nervous conditions is demonstrated. ‘The slow pulse from 
pressure (head pulse) or as seen in meningitis, or under the 
influence of digitalis, is shown when possible. 


“FOURTH CLINIC—RESPIRATORY AFFECTIONS; PNEUMONIA 
“The nurses are taken to the bedside of an acute pneu- 
monia case, after having been given a short talk on the 
disease, and asked to make a note of what they observe 
that is not normal. Itis expected that they will notice 
the— 
Face. 
Respiration (rate and character). 
Tracheal rales, if present. 
Cough. 
Character of sputum. 
Temperature-chart. 
“The chest is inspected and the nurse expected to see 
any differences in the movements of the two sides, and to 


Seat kV EN GS Y MEP TOMS 121 


observe the intercostal spaces on both sides carefully for 
alterations from normal. ‘Tactile fremitus is felt. Dif- 
ference in percussion-note is demonstrated. Vocal frem- 
itus, bronchial breathing, whispered voice, and rales are 
listened to. ‘The above exercise is given in a way to im- 
press the nurse that to observe accurately, the whole atten- 
tion must be on the matter in hand. 


“FIFTH CLINIC—TUBERCULOSIS 

“This exercise is intended to bring out more clearly 
the salient points of the preceding lesson. The same 
method is used as in exercise four, and results contrasted 
with those in that exercise. Less time is given to the clini- 
cal side of this disease, and more to the preliminary talk, 
especially to emphasize the importance of prophylaxis 
and the lines along which this should be carried out. 

“The above five clinics are always given in order. 
Other exercises may, however, be put in between any of 
these if rare or especially interesting cases are in the house 
or an epidemic (as typhoid) is prevailing. 

“The following exercises are given when the clinical 
material warrants, but not necessarily in the order below, 
although this order is preserved when possible: 


“SIXTH CLINIC—PLEURISY WITH OR WITHOUT EFFUSION, AND 
EMPYEMA 


“These conditions are shown on typical cases, the same 
plan being used as in above exercises. Aspiration is shown 
when practicable, and the apparatus for tapping the chest 
is demonstrated, each nurse assembling and using it her- 
self, that she may understand the principles of its action. 


122 OBSERVING 8 YM PPOs 


“SEVENTH CLINIC—TYPHOID FEVER 
“Preliminary talk includes a few words on shape and 
size of bacteria in general. Source of infection and pro- 
phylaxis are emphasized, special reference being made to 
care of excreta in the city and in the country. Cause of 
mental condition and causes of death are explained, and 
the danger-signals of these latter conditions are dwelt upon. 
“As many cases are shown as possible. 
The appearance of the face noted. 
Rose-spots shown. 
Spleen palpated. 
‘Temperature-charts examined and changes in tem- 
perature and in pulse-rate explained. 


“EIGHTH CLINIC-RHEUMATISM 
“As many types of rheumatism and rheumatoid affec- 
tions as can be obtained at the time are shown. The 
dangers and signs of danger are emphasized, especially 
regarding the heart. The untoward effects of certain 
antirheumatic drugs are illustrated when possible, and 
considerable emphasis placed on the signs and symptoms 
that may be caused by these medicines. The writer has 
seen more or less severe stomach trouble and annoying ear 
complications arise where these drugs were being forced 
and where the physician was depending on the nurse for 
warning of untoward effects. 
“An endeavor is made to show the following: 
Rheumatic fever. 
Rheumatism. 
Acute. 
Subacute. 


OBSERVING SYMPTOMS 123 


Chronie. 
Sciatica. 
_ Lumbago. 
“A typhoid knee was shown a year ago. 


“NINTH CLINIC—NERVOUS DISEASES 
“The following diseases were shown last year. The 
characteristic signs and symptoms were brought out clearly 
and the nurse expected to note the variations from normal: 
Apoplexy. 
Tabes dorsalis. 
Chorea. 


“TENTH CLINIC—SKIN DISEASES 
“When it can be properly done, erysipelas, impetigo 
contagiosa, scabies, and a case of eczema are shown. 


“ELEVENTH CLINIC—GLANDULAR DISEASES 
“Diseases of this type are shown where practicable. 
Special attention is given to glandular enlargement due to 
syphilis, tuberculosis, and to pediculosis. A case of glan- 
ders (farcy type) was shown last year. 


“TWELFTH CLINIC—MENINGITIS 
“Meningeal cases are shown if practicable. 


“THIRTEENTH CLINIC—ANEMIA 
“Last year we were able to show primary pernicious 
anemia and secondary anemia from gastric hemorrhage 
in beds side by side. The hemoglobin estimation test 
with the Talquist scale was performed by each nurse. 


124 OBSERVING SYMP POMS 


The nurses are also taught in this exercise, or in any other 
where there is time, to make blood smears, and also smears 
from the other secretions. 


“FOURTEENTH CLINIC—CIRCULATION OF THE BLOOD IN A 
FROG 


“This is shown in the web of a frog’s foot under the 
microscope, each nurse actually seeing the blood flowing 
in an artery, seeing the artery break up into capillaries, 
and the capillaries again pour their blood into a vein. At 
this exercise the processes of inflammation are demon- 
strated. ‘The nurse sees the blood-stream increase in rate 
of flow under slight irritation and slow up under continued 
irritation and finally stop. The inflammatory exudate 
is then examined under the microscope and its character- 
istics noted. 

“At this exercise a nerve muscle preparation is made, 
using the gastrocnemius muscle of a frog. Muscle con- 
traction, caused by direct irritation and by nerve stimu- 
lation, is demonstrated. A specimen of fresh blood is 
examined under the microscope. 


“FIFTEENTH CLINIC—AUTOPSY ON A CAT 

“A regular autopsy is performed on a cat. ‘The nurses 
examine the organs, note their location, and are shown the 
various tissues which they have previously studied in their 
anatomy course. The larynx, eye, and tongue are dem- 
onstrated. 

“Tn addition to the above, the following phenomena 
were shown during the course last year: 


Cbs eR VIN G SOY MePok OMS 125 


Tympanites. 

Loss of liver dulness. 

Abdominal retraction. 

Edema. 

Heart. 

Kidneys. 
Malignant disease. 
Facial paralysis. 
Nephritis. 


Certain speech peculiar- . 


ities. 

Taches cérébrales. 

Chill contrasted with 
chilly. 

Gangrene. 

Cyanoses. 

Emphysema of chest-wall. 

Stigmata. 

Knee-jerk. 

Rose-spots. 

Ascites. 

Bradycardia. 

Tachycardia. 


Palate reflex. 
Tracheal rales. 
Cheyne-Stokes 
tion. 
Linea albicans. 
Facies. 
Peritoneal. 
Lead line. 
Club-fingers. 
Jaundice. 
Satiny skin of alcoholism. 
Uremic coma. 
Enlarged liver. 
Drug-rash. 
Litten’s phenomenon. 
Goiter. 
Babinski’s sign. 
Ankle clonus. 
Incoérdinate movements. 
Visible peristalsis. 
Purpura simplex. 
Erythema nodosum. 
Angioneurotic edema.” 


respira- 


CHAPTER XII 


Teaching Materia Medica 


How to teach materia medica, how to make it interesting 
to the class, how really to get up any enthusiasm for the 
subject, is one of the problems of every teacher of nursing. 
Teachers have worried over it, student nurses have ago- 
nized over it and wrestled with the lessons, often giving 
up the struggle by going to sleep with “Materia Medica” 
under their pillows. Asa hypnotic, a text-book of materia 
medica is often more powerful in its effects than trional. 
But a certain amount of it has to be taught and has to be 
studied. How shall it be done? What can the teacher 
do to increase interest in this subject? 

In the first place, she must know the things she would 
teach. It is not sufficient to prepare for class by picking 
up a text-book a few minutes before recitation time and 
glancing over it. ‘There must be a definite plan for teach- 
ing the lesson in the teacher’s mind. A lesson that lacks 
plan in the teacher’s mind need never be expected to take 
definite shape or stick in the pupil’s mind. 

This is another subject which custom has decreed must 
be taught by physicians only. We have tacitly admitted 
that nurses were quite capable of arranging a text-book 
of materia medica. Nurses and training-schools, physi- 
cians, and medical critics of literature have given cordial 
indorsement to the two very excellent text-books on the 


subject, arranged by nurses, that are now in general use, 
126 


MATERIA MEDICA 127 


but when it came to the actual teaching of the subject, we 
have held to the idea that it should be done by physicians. 
A physician, by reason of his wider knowledge, certainly 
should be able to handle the subject better than a nurse, 
and some physicians have proved admirable teachers. 
A great many have proved dismal failures. Whoever is 
selected to do the teaching, in justice to the class some 
attention should be paid to the question of how much the 
nurses are really getting out of it. There are at least three 
classes of physicians who attempt to lecture to nurses: 

1. Theman who rambles all over the field at every lecture, 
rarely succeeding in giving the class the salient facts about 
any one drug, and who leaves them in the end with their- 
minds in a confused jumble—practically unbenefited. 
(A supervising nurse counted seventy-five different drugs 
mentioned in one lecture.) 

2. The man who is so exasperatingly thorough, according 
to his own ideas of thoroughness, that he will spend the 
whole evening in going into the minutest details of one 
drug, and by the time the allotted number of lectures has 
been given, he will have only gotten started. He usually 
feels dreadfully abused because he cannot continue to 
lecture throughout the entire year. 

3. The man who finds out before he starts how much 
time is allowed for the course and the ground he is expected 
to cover. ‘This man, before starting, makes out an outline 
for each lecture, taking care that the most important 
points—those that will be of practical value to the nurse— 
are included. He carefully systematizes the whole course, 
and gives the facts to the nurses in concise form, and in the 
way that will be most easily grasped. He directs their 
study. He really teaches. The very same classification 


128 MATERIA ME Dittee 


might be made of nurses as teachers, though they are 
less liable to attempt to teach when they are absolutely 
unfitted for such duty. 

How much of materia medica should a nurse be expected 
to know in order to become an intelligent nurse? No doc- 
tor, much less a nurse, is expected to carry the facts about 
every drug in the pharmacopeia in his memory. Until 
this question is answered the teacher is not ready to begin 
to teach materia medica. In the syllabus of the course 
of study outlined in previous pages only the lectures on the 
subject for the preparatory period are outlined, while it is 
expected that some additional lectures will be given. A 
whole lecture may very profitably be given to alcohol, its 
effect on the healthy body, its use in acute illness; the effects 
desired in such cases; its effect on the nervous system; 
how a nurse may know when it is, or is not, having the 
desired effect, and its contraindications. Another lecture 
may deal with the newer medicines—those that have come 
into more general use within the past few years, such as 
veronal, chloretone, somnal, ichthalbin, scopolamin, ete. 

Another lecture might deal with the various forms of 
foods which come in the shape of medicines, their compo- 
sition, food value, etc. In connection with this lecture 
some very interesting experiments can be arranged, show- 
ing the action on food of various popular digestive prep- 
arations which the nurse will use almost constantly. While 
this teaching may be included in the course on dietetics, 
it may just as properly be included in this course, since the 
materials dealt with are pharmaceutic preparations. 

There are interesting facts connected with many of the 
drugs in common use that may be brought out, that would 
add variety and interest to an otherwise dry lesson. For 


heey he eT A ME DT CA 129 


instance, belladonna, the drug so much used in eye work, 
is now being very successfully cultivated in New Jersey, 
the seed being sown in the conservatories in February 
and the plants maturing late in September. The quinin 
we use is obtained from the cinchona tree, which was named 
in honor of the Countess of Cinchon, the wife of a governor 
of Peru, on whom it was used in a fever with very gratifying 
effects. ‘The medicinal properties of the bark of the tree 
had long been known to the South American Indians, but 
its value had not been generally recognized by the medical 
world previous to its use on her case by one of the court 
officials. ‘These are only a few examples of facts that may 
be interspersed with the teaching that will help to change 
a subject that seems, at first sight, dry and hard and unin- 
teresting to one that is, if not fascinating, at least bordering 
on it. It depends greatly on the command of the subject 
the teacher has and the amount of brightness and energy 
he puts into it. 

A whole lecture can very profitably be devoted to a dis- 
cussion of animal extracts and sera. ‘The study of the 
methods of obtaining the various sera and animal extracts 
now on the market is unusually interesting. While the 
therapeutic value of many of the sera is disputed, and the 
subject is one on which there is certain to be a wide differ- 
ence of opinion for years to come, yet the value of some has 
been proved beyond question. The serum for tuberculosis 
has thus far disappointed hopes; the serum for typhoid 
fever is being experimented with, and has yielded good 
Tesults in some cases; the serum for dysentery has not come 
up to expectation; and antipneumococcic serum has not 
proved of practical value‘ the serum for hay-fever is said 


to mark a significant advance in the treatment of disease; 
2. 


130 MA T.\E RA: ME Die 


the tetanus antitoxin has markedly decreased the mortality 
from that disease. Of all antitoxins, the diphtheria anti- 
toxin has given the most satisfactory results. It is the one 
with whose effects the nurse will probably become most 
familiar in general practice. ‘These sera are obtained in 
a great variety of ways. Extensive experiments are now 
being carried on, and there is or seems to be a widening 
field for serum-therapy. From the manufacturers of 
biologic products pictures illustrating the different steps 
in the process of preparation of vaccine, sera, etc., can be 
secured that will not only make a dry subject more inter- 
esting, but will give a clearer idea than any words alone 
could convey of the very great care that is taken in the 
preparation of these products, the cost of them, and the 
points to be guarded against in handling them. 

“‘ All nature, animate and inanimate, has been laid under 
contribution to provide remedies for the alleviation of dis- 
ease.” The animal, vegetable, and mineral worlds have 
all furnished of their products. Samples of crude drugs 
can usually be obtained from chemic laboratories that will 
add interest. Nurses are but children of a larger growth, 
and anything in the line of an object-lesson helps them to 
a clearer understanding. If the teacher could visit some 
of the laboratories of manufacturers of pharmaceutic pro- 
ducts and see medicines in the making, she will see much 
that is of practical value in teaching the subject. 

Text-books of nursing all contain definite instruction 
about the administration of medicines, but in the school 
of experience the teacher has learned a great deal about 
the question that is not usually included in the text-books. 
Drug accidents are, unfortunately, not rare. Ever and 
anon reports are heard of another patient who has come 


PeeA EEO YAY MID cera 131 


to an untimely end in a hospital from the administration 
of a wrong dose. Such accidents may serve a good purpose 
in every hospital if brought to the attention of nurses, and 
their responsibility in handling medicine is thus more 
strongly impressed upon them. Constant familiarity is 
very apt to lead to carelessness, unless reminders of pos- 
sible dire consequences are very frequent. 

There is another phase of the subject that may well be 
emphasized in dealing with every class. Very often in 
actual experience it is left to the nurse’s judgment to give 
or withhold a drug. Occasionally it has been noticed 
that some nurses gave morphin and sleep-producing drugs 
more frequently than the occasions seemed to warrant. 
In fact, it is admitted and regretted, by a great many who 
know whereof they speak, that the use of hypnotics and 
narcotics is far too common both in the hospital and out 
of it. Of course, in the hospital this is, in the final analysis, 
the physician’s responsibility, since every patient is in 
charge of some physician. If he leaves no orders or says 
absolutely that certain drugs must not be given, they are 
not given. If he says they shall be given, they are given. 
But there are still a great many cases in which he does not 
say the one thing nor the other. Ifa patient wants a drug, 
he often permits it to be given, but does not distinctly order 
it. He leaves the nurse to decide whether it is needed or 
not. There have been cases when, because a patient was 
troublesome, the nurse has been known to report a very 
much more serious condition than facts warranted, in order 
to get permission to give morphin; or has given a dose of 
some hypnotic because she was permitted to, without 
attempting to woo sleep in any other way. The majority 
of nurses will not be thus guilty, but it is safe to say there 


132 MATERIA MEDPGey 


will always be some, in a school of any considerable size, 
who will. These are undesirable and delicate questions 
to discuss, but in view of the steady increase in the ranks 
of the neurasthenic, hysteric, and insane, of the growing 
number of drug habitués, the question of a nurse’s respon- 
sibility in administering hypnotics is one that demands 
serious treatment on the part of teachers and supervisors. 

The same is true about the use of aleohol. Some nurses 
will freely use it for flavoring fluid foods, when it had not 
been ordered by the physician to be given in any way, 
and have thereby stirred up an appetite that had been a 
source of weakness and sorrow and remorse to the patient, 
and which he was struggling to overcome. Many times 
these unfortunate incidents are the result of sheer thought- 
lessness, which clearly shows the need of plain teaching 
on these points. 

Hubert Richardson, M.D., of Baltimore, in the “ Diet- 
etic and Hygienic Gazette,” January, 1907, in writing on 
“The Treatment of Insomnia,” gives some results of his 
observations in the use of a number of hypnotics which 
may be of help in teaching these lessons. “Opium,” he 
says, “is probably most used even when there is no pain, 
and it certainly does not produce the conditions for normal 
sleep. . . . It is evident that instead of producing 
the conditions for normal sleep, opium causes unconscious- 
ness by intoxication, which may or may not be followed by 
sleep; the centers of consciousness are not at rest, but 


poisoned. 
“Paraldehyd produces a condition resembling sleep, and 
is described as being perfectly harmless. . . . I have 


seen a victim of the paraldehyd habit who, upon failure 
to get his dose, was thrown into an intensely nervous con- 


MATERIA MEDICA 133 


dition resembling mania. Gradual reduction of the drug 
‘ was impossible, as the patient knew the odor, and knew 
at once when the dose began to get low; finally, the drug 
was stopped altogether, and after a week of maniacal excite- 
ment he recovered. Another instance was an alcoholic, 
who had been taking a nightly dose for some weeks. He 
developed a mild attack of acute uremia with edema. 

On stopping the drug without any treatment, the elimina- 
tion of urea rose to 84 gm. in twenty-four hours, and the 
total quantity of urine to 2500 c.c. 

“Chloral produces effects which are more likely to pro- 
duce natural sleep. . . . Although its physiologic 
action comes nearer producing the circulatory conditions of 
normal sleep, it must act as a poison, for the chloral 
habit soon shatters the constitution. 

“Bromids reduce respiration and slow and weaken the 
heart, being a direct nerve poison, producing sluggish 
reflexes and defective codrdination. 

“Hyoscin hydrobromate, if its use is prolonged, is apt 
to derange the mental faculties. 

“Sulfonal and trional are probably more used than any 
other hypnotics, both by the profession and the laity. 
Potter, quoting Squibb, says that ‘if it were not for the 
very evident advantage of sulfonal when used with care 
and under medical supervision, it would probably be either 
excluded from practice or its sale restricted by legislative 
authority.’ It produces its hypnotic effect by direct action 
on the brain-cells, and upon the red corpuscles by dissolving 
lecithin. A dose of 20 grains is invariably followed by a 
large amount of hematoporphyrin in the urine, showing 
a marked destructive power on the erythrocytes. 

“The other hypnotics on the market have practically 


134 MATER TDA) ME Diver 


the same effects as those mentioned; that is, they produce 
sleep by intoxication and are, therefore, poisonous. ‘The 
physiologic action of the bromids and of chloral come near- 
est to producing normal hypnotic conditions, but their 
toxic conditions are well known.” 

Plain facts about these drugs need to be stated to nurses 
while in training. While joining in the crusade against the 
use of patent medicines as opportunity offers, it is certainly 
wise to do a little special crusading against the wnnecessary 
use of this class of remedies, and to emphasize the numerous 
simple measures that a nurse can use that may, in a great 
many cases, render their use unnecessary. 


MEDICINES AND FOODS 

Still another point regarding the giving of medicines 
that is often slighted in teaching is concerning medicine 
in its relation to food. In arranging the hours for the 
administration of medicine much is left to the discretion 
of the head nurse in the hospital or the nurse in charge 
of the case in private practice. When the directions simply 
read: ‘‘One teaspoonful every four hours,” shall the nurse 
arrange the hours beginning at six, seven, eight, or nine? 
The particular effect such medicine will have on the food 
the patient is taking should be one determining factor in 
fixing the time. 

“So little is really definitely known of the intricate chem- 
istry of digestion and assimilation,” says W. Gilman 
Thompson, in “Practical Dietetics,” “that it is difficult 
to formulate rules for the right time of giving every drug in 
relation to fulness or emptiness of the stomach. The 
reaction of the stomach-contents varies from alkaline to 
neutral and acid, and these several reactions will decom- 


moeowk REA MEDICA 135 


pose medicines in various ways. Besides this, the reac- 
tions themselves are dependent on a large number of 
organic acid salts, and other substances which may wholly 
alter the composition of medicines at one time, and not be 
present to affect it at another. A drug given after a full 
meal may be decomposed by the strong hydrochloric acid 
of active digestion, which is unaltered in an empty 
stomach. 

“The following rules are subject to many exceptions, 
but they will serve as a general guide: 

“Alkalis are best given shortly before meals unless de- 
signed to neutralize hypersecretion of hydrochloric acid. 

“Acids should be given within half an hour after meals. 

“Bitters should be given before meals. 

“Remedies, such as iron and arsenic, which may prove 
somewhat irritant to mucous membrane, should be given 
either soon after the regular meals or after taking some 
simple article of food. Ammonium carbonate and potas- 
sium iodid, for example, may be prescribed in milk. 

“Most cough medicines, cardiac tonics, diuretics, and 
systemic remedies which are not especially irritating to the 
stomach should be taken between meals. ‘They will be 
more prompily absorbed from an empty stomach, and are 
less liable to be altered in composition by digestive fluids 
or to inhibit digestion. 

“Remedies designed to act in the intestines and not in 
the stomach, such as salol, should be given at the end of 
gastric digestion, when the stomach-contents are about to 
pass into the intestine. 

“Saline laxatives should always be taken at least half an 
hour or an hour before meals, preferably before breakfast; 
but the stronger, more slowly acting cathartics should be 
given on an empty stomach before retiring.” 


136 MATERIA MEDRGe 


While there may be numerous exceptions to these rules, 
yet they can be used in impressing on nurses the necessity 
of careful observation of the effects of medicine as it relates 
to food and its possible connection in producing vomiting 
or other gastric disturbance. 

One phase of the subject is duly emphasized in training- 
schools—that nurses are not to prescribe; and we refuse 
to believe there is, or ever has been, in the history of nursing 
in America, any real reason for physicians to be greatly 
alarmed about nurses in general deviating from the narrow 
path in this respect. It is hard to get up any genuine 
sympathy with the resolutions concerning nurses that were 
unanimously adopted by the Congress for the Suppression 
of Illegal Practice. Regarding this resolution: “The pro- 
grams of nursing schools, and the manuals employed, 
should be limited strictly to the indispensable matters of 
instruction for those in their position, without going exten- 
sively into purely medical matters, which might give them 
a false notion as to their duties, and lead them to substitute 
themselves for the physician.” Many will be in absolute 
accord with the need of confining the studies to the things 
essential or of practical value to a nurse, but with the reason 
given, lest they may “attempt to substitute for the physi- 
cian,” they will absolutely disagree. ‘The real reason is ' 
because there is so much that is essential for a nurse to 
know, in the limited time she has for study while in training, 
that she has no time nor energy left to make excursions 
into purely medical fields. ‘There never was a fold in 
which there was not an occasional black sheep found, and 
so long as nurses are human, some nurse will, once in a 
great while, blunder in this respect, and need to be severely 
reproved. She will do this in spite of the fact that she 
knows better. 


CHAPTER XIII 


Teaching Bacteriology and Surgical 
Technic 


How much should nurses be taught regarding bacteri- 
ology? ‘There is clearly a great deal concerning the sub- 
ject which they need not be taught—at least as undergrad- 
uate students. In order to render efficient service to 
the sick, the nurse need not be required to burden herself 
by attempting to penetrate into the mysteries of plate 
cultures, tube-cultures, or the manufacture of the various 
forms of culture-media. She need not know anything 
about differential staining, microscopic work, or the 
elaborate technic of a bacteriologic laboratory. She should 
know something of the general theory of the subject, 
something about bacteria in natural processes, of the con- 
ditions necessary for development and multiplication; 
something of how bacterial diseases enter the system, 
and how the germs of disease are thrown off in common 
communicable diseases. She should know how immunity 
may be secured, and should be thoroughly familiar with 
preventive measures. She should know something about 
the bacteria encountered in surgery; the principles on 
which aseptic surgery is based; the channels by which 
organisms may reach wounds; the principles of steriliza- 
tion and disinfection. Beyond this she need not go in 
order to be a good, practical, intelligent, efficient nurse. 


Just how long should be spent in acquiring this knowl- 
137 


138 BACTERIOL OG® 


edge, how many class hours are necessary, depends very 
much on who is to do the teaching, how clearly and con- 
cisely the necessary theory is presented. Bacteriology 
can be presented to probationers and junior nurses so 
that it becomes an intensely interesting study. It may 
be fired at them in such a manner that they will feel hope- 
lessly confused and dejected, overburdened, either with 
a sense of their own stupidity or the teacher’s, and carry 
from the class only a confused jumble of dreadful words 
which to them are utterly devoid of meaning. 

Should it be taught by physicians or nurses, is another 
question that is sometimes asked. A physician who knew 
the practical needs of nurses along this line, and knew 
his subject thoroughly, should be in a better position to 
handle the study than a nurse, if he is able to put his knowl- 
edge into language which the pupils will readily com- 
prehend. ; 

As an illustration of how not to attempt to teach bacteri- 
ology, the following is cited: A physician, prominent in 
medical circles, had been invited to teach bacteriology 
to a class of beginners in nursing. The superintendent 
endeavored to impress on him the necessity of couching 
his lecture in the simplest possible language. 

“Yes, ma’am,” he replied, “I always use simple terms 
to express my thoughts. The cleverest men always do.” 

He began by entertaining the class by telling them of 
his surgical feats, of the many difficult operations he had 
performed, and the remarkable success that had attended 
them. Then he launched into the subject, and told 
them of all the germs he could think of that had been 
discovered, being careful to call each germ by its strictly 
technical name. He rolled these names off in such rapid 


Bea CTE RTO. OGY 139 


succession that the entire class gave up trying to take 
notes, and sat gazing at him with mingled feelings of 
curiosity, awe, and amusement. 

“The Staphylococcus pyogenes aureus, where is its 
habitat?” he exclaimed in tragic tones. ‘Where is the 
habitat of the Streptococcus pyogenes, or of the Bacillus 
coli communis ?” 

Echo alone answered, “Where?” The class were too 
thoroughly awe-stricken to tell, if they had had any idea. 
After it was all over, and the man who “always used sim- 
ple language” had gone, the superintendent, who was 
present, met the dejected-looking probationers, and ex- 
plained what he was trying to talk about. 

An introductory talk on the subject by a superinten- 
dent or head nurse, before the study of the text-book is 
attempted, will usually result in making the lessons which, 
at first glance, appear difficult, more interesting and 
decidedly easier of comprehension. 

Acting on the principle that it is always wise, when possi- 
ble, to begin with facts which the class know or have 
observed, and proceed in natural order to the unknown 
facts which it is desired they should grasp, such a pre- 
liminary talk might begin by a discussion of dust. Every 
pupil has observed the tiny floating particles of dust that 
show so plainly when a ray of light streams in through 
an opening in the shutter. They may not have considered 
that the air is always thoroughly mingled with these float- 
ing particles, though the particles are not always visible. 
The constituents of dust, the difference between the com- 
position of the dust in the ordinary house and the hospital; 
the necessity of removing this dust, as far as possible, 
and of preventing it settling on wounds, dressing mater- 


140 BACTERIOL OG 


ials, or becoming mingled with foods; the soil and condi- 
tions necessary for the development of disease-producing 
bacteria; the functions of the good germs—these facts 
can all be presented in a way that will be clear and as 
fascinating as a story if the lecturer knows how to clothe 
facts in interesting story form. 

Lectures on bacteriology are likely to be of very little 
use to nurses as compared with the plan of teaching by 
recitation from a text-book specially prepared for nurses. 
The student needs the printed page. If, at the beginning 
of the study of the subjects, tubes containing different 
germs in process of development in culture-media can be 
shown, it will help to make clear the methods of group- 
ing and the conditions necessary for development, and 
will add interest. Laboratory demonstrations are always 
interesting and usually valuable, but because this is true, 
it does not follow that nurses should be obliged, in their 
probation term, to spend twenty-four class periods in a 
pathologic laboratory, making “a careful study of the 
more common pathogenic organisms, such as tubercle 
bacillus, the pneumococci and gonococci, and the germs 
of typhoid fever, diphtheria, and tetanus,” as one modern 
training-school requires, or that the nurse will be any more 
efficient in the sick-room because of the twenty-four class 
periods spent in the pathologic laboratory. 

This is another example of a good method carried to 
extremes. No one believes that this amount of experi- 
ence in a pathologic laboratory will do her any harm, of 
necessity, but will it do the nurse any good? Has she 
time for it? Is it necessary? Are hospitals under obli- 
gation to furnish this amount of instruction to nurses in 
pathologic laboratories? If so, what of the hospitals 


SUNWGLCALT TECHNIC 141 


that have no such laboratories connected with them? 
Must they also provide for this laboratory training in 
some way? Is it one of the real essentials of nursing? 
If it is necessary for one class of nurses, it ought also to 
be necessary for all. If it is not necessary for all, why 
should it be required of any? ‘These are all practical 
questions that suggest themselves at this point, and deserve 
to be considered by hospital people in general. 

A method that always teaches a valuable lesson is to 
take the scrapings from beneath the finger-nails of some 
members of the class, both before and after hand disinfec- 
tion has béen attempted, and by means of culture-media 
show how dangerous this matter is. Another practical 
lesson is sometimes taught by putting a piece of sterile 
gauze, smeared with pus, into a room about to be fumi- 
gated, and afterward testing to see whether disinfection 
had really been accomplished. Some emphasis may be 
placed on disinfection of typhoid stools, and the conditions 
that weaken the power of the disinfectant used or render 
it inert. A great many people believe that much of the 
so-called typhoid disinfection is simply going through 
the motions. In a great many cases the disinfectant is 
weakened by the presence of urine, or a considerable 
amount of fluid, or the matter is consigned to the sewer 
before the disinfectant could possibly disinfect. 

In teaching nurses the necessity of keeping surgical 
dressings, appliances, wounds, etc., covered so as to pre- 
vent the entrance of dust, the following experiment, which 
does not require a pathologic laboratory apparatus to 
make the trial, has been used. Before the lesson in 
theory begins two potatoes, two knives, two forks, two 
plates, and two small basins or bowls have been placed 


142 SURGICAL TECH Re 


in an instrument boiler, and thoroughly sterilized by 
boiling. In the presence of the students, one potato is 
removed from the boiler with the sterile fork, laid on the 
sterile plate, cut in half with the sterile knife, and imme- 
diately covered with the sterile bowl. The other potato 
is handled in the same way, except that it is not imme- 
diately covered. It is left, for a half-hour or more, ex- 
posed to the air and floating dust, then covered, and the 
two sets of material are locked up for a week or until the 
next class on the subject is held. It will usually be found 
that the potato that has been exposed to the dust after 
sterilization will show a large number of colonies of germs 
in course of development, while the other will be com- 
paratively free. 

As an introduction to the teaching of surgical technic, 
this experiment and the test regarding the scrapings from 
beneath the finger-nails will prove valuable and yield good 
results. 

With almost any of the numerous text-books on sur- — 
gical technic as a basis it should not be difficult, after the 
first principles have been grasped, to teach the details of 
practice, and help each nurse to acquire a good system 
that can be carried out in a private home even of the 
meanest type. All nurses will not become equally good 
surgical or operating-room nurses. All nurses will not 
remember, nor observe, all the principles of surgical 
technic which they are taught, but it is safe to say that no 
nurse wiil ever acquire a good technic that will render her 
absolutely safe to be left in charge of an obstetric or sur- 
gical patient, unless it is built on the foundation of a sim- 
ple working knowledge of bacteriology. She must be 
taught the “why” of things to a certain extent, or a great 


Poe GleCAL TECHN IT €¢ 143 


deal that she is required to do, in a hospital or elsewhere, 
will not be properly done. A good surgical technic can 
never be acquired by repetition of a series of meaningless 
“do’s” and “don’ts” with an aseptic application. 


CHAPTER XIV 


Teaching Obstetrics 


How much should a nurse be taught regarding obstet- 
rics? Considering that the average nurse who goes 
into private practice usually has at least five obstetric 
patients to one operative patient; considering that a nurse 
may be called the day after graduation to an obstetric 
case in which serious complications are present, and where 
two lives are in danger, it will readily be admitted that 
she ought to be taught a great deal about this branch of 
nursing. ‘The hospital that sends her out with its diplo- 
ma certainly has the responsibility of seeing to it that she 
is well equipped by efficient theoretic and practical instruc- 
tion and experience to take the place as an assistant to 
the physician that a nurse who calls herself a graduate 
ought to take. 

Regarding the conditions of obstetric training that exist 
in one of the largest cities, a writer* in 1906 made the 
following comment: 

“Even today in all but perhaps one or two of our hospi- 
tals the obstetric ward is the cast-off, otherwise useless, 
portion of the general hospital; its equipment is made up 
of the old utensils of the surgical operating-room, cast off 
when the latter was fitted with new apparatus, and its 
technic is the surgical technic remodeled by the individual 
nurses to fit what they might think best meets the con- 
ditions. 


* Mrs. Emma Koch, Superintendent Chicago Lying-in Hospital. 
144 


meee CHING OBSTET. RECS (145 


“The head nurse almost always has other duties com- 
bined with her obstetric work, her nurses are under her 
instruction but a few weeks, and usually for only a few 
minutes each day, the visits of the ‘attending man’ usually 
resemble a draft along the corridor, and her support and 
fountain of information remain the interne, who stays the 
long period of six weeks in the service, and whose place 
is filled by another equally well supplied with obstetric 
knowledge and an obstetric technic. 

“Tt is no wonder, in view of these things, that the nurse 
leaves the obstetric ward with a feeling of relief and often 
disgust. She has worked hard, has learned little, has 
obtained no enduring methods, has seen no ideals of prac- 
tice and has attained none. 

“A crying baby means peppermint water and nothing 
else; an incubator baby is a nightmare of blue spells; 
a puerpera means nothing more to her than castor oil and 
external dressings, etc. She has not been taught to ob- 
serve the daily changes occurring in the little being lying 
in the crib; she has not seen the earliest developments 
of the mind; the changes of the skin, of the intestinal 
tract, the circulation; the shape of head and body, and 
all the wonderful phenomena that go to make up life, 
and the preparation of the individual for an adult exis- 
tence. 

“She has not been taught to observe the wonderful 
workings of nature in the puerpera, the recession of the 
uterus, the changes in the lochia, the development of lacta- 
tion, the fluctuation in the body functions. 

“To her a labor is a long vigil of watching suffering, 
and a bewildered assisting at the delivery of the infant. 


The mighty occurrences in the labor are meaningless. 
10 


146 TEACHING OBS LEC See 


The mechanism of labor, the protection nature gives the 
mother against infection and hemorrhage, the change of 
the child’s life from intra- to extra-uterine, all these are 
thrilling and magnetic stories, but a closed book to her. 

“The grandeur of the science of obstetrics thus being 
unknown to the nurse, and the practice of the art being 
so desultory and unsatisfactory, the nurse regards her 
obstetric training as a necessary punishment, and usually 
resolves ‘never to take obstetric cases when she gets out.’ ” 

Whether this description would apply with equal truth 
to obstetric conditions and training in all cities may be 
questioned, but at least it affords food for thought. 

When so many excellent text-books on obstetrics are 
available, there certainly seems no reason why nurses 
should any longer depend on the haphazard taking of 
notes while a physician lectures. Certainly any nurse 
who has been taught the underlying science of obstetric 
work, as given in De Lee’s text-book, cannot enter on her 
real obstetric practice without some idea of “the wonder- 
ful phenomena that go to make up life,” or the “wonderful 
workings of nature’’ in parturition and the puerperium. 
Somebody is certainly very seriously to blame if a nurse 
graduates without a good working knowledge of this 
subject. Even if affiliation with a well-equipped lying-in 
hospital is not possible, or if there is no obstetric depart- 
ment in the hospital, it is still true that obstetric patients 
are not confined to any locality. The nurse can get the 
theoretic instruction in the hospital, and the practical 
work in homes under the instruction of a physician. 
The difficulty lies not in lack of opportunity for wide 
experience, but in the lack of adjustment, and in the limi- 
tations we have been accustomed to place around our 


Pear ca it NG OBS TET REC Ss 147 


training-schools under pressure from different sources. 
lt is a sad commentary on our civilization, and also our 
nursing progress, when it can be said that children are 
born under indescribable conditions in many of our cities, 
without any intelligent care or assistance to a mother 
during the crucial period, and, on the other hand, that 
nurses are still being graduated without ever having had 
a chance, while in training, to wash a baby, to assist at a 
childbirth, or care for a woman during the puerperal 
period in a hospital or out of it. To assist at a birth and 
care for a mother and baby in a well-equipped hospital, 
with a sterilizer and instrument boiler and all the parapher- 
nalia of a well-furnished delivery room, is certainly valua- 
ble experience. The training in the right way to manage 
the situation is very necessary and desirable. But to 
care for such a case in the cellar of a tenement building, 
without a basin in which to wash the nurse’s or doctor’s 
hands, or a towel to dry them; without a clean sheet to 
put on the bed or a clean gown for the patient; to manage 
such a case so that the mother may make a good recovery 
and the baby a good start, is a far greater achievement. 
In writing on the ideal obstetric training for nurses, 
Dr. A. Worcester, in “Boston Medical and Surgical 
Journal,” has said: “Obstetric nurses should be ex- 
pected to exercise precautionary surveillance during the 
pregnancy; to manage the first stage of labor; to recog- 
nize any abnormal occurrence; to be able to conduct a 
normal labor; to apply appropriate preliminary treat- 
ment in emergencies, and in confinement to care for both 
mother and baby intelligently. The ideal education of 
the obstetric nurse includes still more. She must be taught 
how to fit in most helpfully in homes where the mother is 


1448 TEACHING OBS PEAR 


under temporary eclipse; to save unnecessary expense, 
and to make the family, and even the servants, her friends.” 
In arranging a clinical demonstration of methods to be 
used in obstetric nursing, there is room for plenty of origi- 
nality to express itself. Among other things, how to pre- 
pare for a normal labor, how to wash and dress a baby, 
the dressing of the cord, the care of the mouth and eyes, 
massaging of the mother’s breasts, the use of the breast- 
pump, the application of abdominal and breast binders, 
should be included. Some very excellent points for such 
a demonstration may be obtained by a study of the num- 
erous illustrations in De Lee’s “Obstetrics for Nurses.” 


CHAPTER XV 


Teaching Gynecology 


How much should a nurse know about the diseases 
peculiar to women? A physician was asked by a nurse, 
some years ago, whether he knew of any book on the 
subject of gynecology that would be valuable for her to 
read. He was an eminent gynecologist. She was caring 
for his patients before and after operation. He frankly 
told her that a nurse did not need to know anything 
about gynecology. ‘There is certainly a great deal con- 
nected with the subject with which a nurse need not con- 
cern herself, but, with all due deference to the opinion of 
the eminent gynecologist, there is a good deal that she 
does need to know. 

First, she needs to know something of the anatomy of 
the parts concerned in gynecology and their relation to 
each other. She can be a very efficient nurse if she never 
hears of the pampiniform plexus, the infundibulopelvic 
ligament, if she cannot “describe the arterial supply of 
the uterus” or remains ignorant of hundreds of other such 
points, which some modern physicians attempt to teach 
her in the belief that “it is nice for her to know all these 
little details.” She need not even know all the names 
applied to the great variety of diseased conditions of the 
organs concerned, but she should know something of the 
commoner diseases with which she will have to deal. 


She should be taught, in an elementary way, something 
149 


150 TEACHING GYNECOLOGY 


regarding the diseases of the external genitals and vagina, 
something about venereal diseases, something regarding 
injuries to the pelvic floor and perineum, something regard- 
ing disturbances of functions. ‘The disturbances of men- 
struation should be given special attention. 

Another point that has been emphasized in recent years, 
and properly so, is the necessity of an earlier recognition 
of cancer of the uterus. Progressive physicians, in view 
of the prevalence of this disease and the impossibility of 
dealing with it at all successfully after a certain stage has 
passed, have insisted that nurses should be instructed 
thoroughly regarding the earlier manifestations of the 
disease; that they should use every opportunity to instruct 
women in general regarding these early signs and the 
importance of prompt treatment. ‘They urge that nurses 
should do what they can to save women from wasting 
time on quack remedies until all possibility of a cure has 
passed. Dr. S. M. Hay, in a lecture to nurses in Toronto, 
has stated very clearly and concisely the following facts 
which nurses should know regarding this disease: 

“That the four symptoms that stand out prominently 
in cancer of the uterus are: Hemorrhage; discharge 
(leukorrheal or watery, and these may precede the hemor- 
rhage); pain; general constitutional symptoms. 

“1. That cancer of the uterus is prone to occur between 
the ages of thirty-five and fifty-five. It may, in exceptional 
cases, come earlier or later. 

“9. That it is a local growth at first, and curable in its 
early stages. 

“3. That irregular and unusual uterine bleeding at any 
time of life, but more especially between the ages of thirty- 
five and fifty-five, is a symptom requiring investigation. 


ewe HING GYNEC OE OGY > 151 


“4. That the return of the flow, after the establishment 
of the menopause, is one of the gravest of symptoms. 

“5. That leukorrhea is a symptom of diseased condi- 
tion requiring investigation, but too frequently neglected. 

“6. That change of life means cessation of menstrua- 
tion, and that increased flow at a time when menstruation 
is expected to cease is a danger-signal. 

“7, That pain is a symptom that appears late, and 
should: not be expected or looked for as a sign of cancer 
in the early stages.”’ 

Lectures on gynecology should be given by physicians, 
but there is a good deal that a nurse ought to know about 
such work as gynecologic nursing that she will not know 
thoroughly and properly unless a head nurse or superin- 
tendent teaches it. Unless a doctor has at some time 
been a nurse, he is not likely to remember the multiplicity 
of details that enter into success in that branch of a nurse’s 
work. 

Perhaps, next to bed-making and the general care of a 
patient, to give a vaginal douche will be one of the nurse’s 
first duties in a gynecologic ward. Before a nurse is or- 
dered to give a vaginal douche she ought to know some- 
thing of the requirements of a douche, its value as a reme- 
dial agent, the amount of fluid needed, the temperature, 
position, duration, and something of the objects it is 
supposed to accomplish. With all our boasted progress, 
there are still nurses being allowed to graduate after a 
three years’ course who have not been taught these sim- 
ple fundamental principles. A nurse who had been ad- 
mitted to a hospital for postgraduate training was sent 
to give a douche to a patient by way of preparation for a 
vaginal operation. A few minutes before the clinic hour 


152 TEACHING GYNECOLOGY 


the head nurse was amazed to find that the douche had 
been given without having removed a filthy, odorous 
tampon, the strings of which were plainly visible; indeed, 
the tampon was in the way of the insertion of the nozzle. 
This nurse was a graduate of a prominent hospital in one 
of the Central States—a hospital that would probably be 
registered without question because it is a general hospital, 
has over a hundred beds, a large proportion of them 
always occupied, and gives a three years’ course of training. 

Another point on which many nurses are weak is in 
not knowing how to place patients in the different positions 
for examination. Such examinations are too often con- 
ducted without any method on the part of the nurse, 
because of imperfect teaching at this point. A clinical 
demonstration should explain these points clearly to every 
nurse, so that she fully understands what her duties are 
under the circumstances. The methods of examination 
should be first explained. These may be classed, for 
convenience, into non-instrumental and _ instrumental. 
The non-instrumental methods include inspection of 
external genitals, external abdominal examination, bi- 
manual examination, rectal examination. The class 
should be shown how to put a patient in the various posi- 
tions for these examinations. A very sensible practical 
test of a nurse’s progress along these lines would be to 
require each nurse at different times to put a patient in 
Sims’, lithotomy, knee-chest, upright, dorsal, Edebohls’, 
and 'Trendelenburg’s position. She might be able to 
write down how it ought to be done, and yet not be able to 
do it promptly, properly, and with the least exposure of 
the patient. 

The instruments necessary for instrumental examina- 


EEA CHING GYNECOLOGY 153 


tions, or for use in vaginal work in removing sutures from 
the cervix, etc., should be shown in this lesson. The 
difference between the spatular speculum, commonly 
know as Sims’, and the bivalve speculum should be ex- 
plained. Instruction should be given as to how to assist 
a physician in instrumental examinations. The prepa- 
ration for an intra-uterine douche, how to arrange the 
patient, and help the doctor during its administration 
should not be overlooked. 

If time allowed, or -in a future lesson, the method of 
preparing a patient for gynecologic operations, both 
abdominal and vaginal, should be shown by practical 
demonstration, even if the regular nurses of the hospital 
are not required or allowed to do this work, or if it is 
always done in the operating-room. Another illustration 
from a postgraduate school will emphasize this point. 
A nurse in private practice came with a patient to the 
hospital as a special nurse. ‘The case was one of multiple 
fibroids, to be operated on through the abdomen. The 
surgeon gave directions for preparing the abdomen—the 
shaving, scrubbing, compress, etc. The nurse was a 
graduate of one of the oldest, largest, and best-organized 
hospitals of the Eastern States. So far as the postopera- 
tive care was concerned, she was all that could be desired. 
But she was obliged to come to the head nurse and confess 
that she had never prepared a patient for operation and 
did not know just how to go about it. This happened a 
few years ago. Perhaps it could not happen now, but it 
serves to show the need of every superintendent making a 
business of seeing that her nurses get practical instruction 
along these lines. 

Such a demonstration as has been suggested might 


1544 TEACHING GYNECOLOGS 


conclude with methods of preparation and application of 

tampons and adjustment of abdominal and perineal band- 

ages. Not a few wounds become infected because the 

nurse either has not been instructed as to how to adjust 

such bandages, or because she neglects to keep watch 
that they remain in position. 


CHAPTER XVI 


Teaching Private Nursing and Visiting 
Nursing 


Whether or not a pupil nurse should be allowed to gain 
experience in nursing in private homes during her training 
period has been a much-disputed question. There will, 
however, hardly be any dissent from the statement that 
the training-school owes it to the nurse to give clear, 
pointed teaching on the subject theoretically, teaching 
that will help her to enter on that line of work with some 
understanding of her place in the home, and what she 
may expect to encounter after she graduates if she does 
private nursing. 

The requirements for this line of nursing are so decidedly 
different from the requirements for hospital work that it is 
little wonder that so many failures and misfits are recorded 
among private nurses. In the hospital the nurse is sur- 
rounded with all sorts of conveniences for her work; 
there is always some one who shares the responsibility, 
and her duties are fairly well-defined. In the home, all 
this is changed. It is true that experience in this, as in 
all lines of human activity, must always be the best 
teacher, and no amount of teaching could possibly pre- 
pare her for every emergency that might arise, but some 
instruction should be given. 

Who should teach private nursing, and along what lines 


should this theoretic teaching be planned, are questions 
155 


156 PRIVATE NUR SIs 


that suggest themselves at this point. ‘The instruction 
is best given by a nurse who is, or has recently been, en- 
gaged in private duty, and who is known to be a successful 
woman, with good common sense. No nurse whose 
experience has been chiefly gained in an institution can 
possibly appreciate the needs or the multiplicity of deli- 
cate points that arise in nursing in homes. 

In beginning a course of instruction on this subject a 
few points may profitably be given a little special empha- 
sis. Itis just as true that special qualifications are needed, 
if one would achieve success in private nursing, as that 
they are needed for institutional work. ‘The one requires 
methodic habits, a nice division of one’s time between a 
number of patients, a careful observance of orders and 
regulations, a certain amount of speed in getting through 
with a number of duties according to prescribed methods, 
and with appliances of all kinds at hand. The other 
requires adaptability to all kinds of situations, a willing- 
ness to sacrifice personal convenience, a study of each 
patient and also his immediate friends and relatives and his 
surroundings, the ability to manage a domestic situation 
so as not to antagonize the people, and the willingness to 
do whatever her hands find to do, that will help toward 
the recovery of the patient. 

There are two faults especially for which private nurses 
as a class have been severely criticized—extravagance in 
their demands and their unwillingness, as a class, to wait 
on themselves or to do what needs to be done for the patient 
outside of a certain well-defined list of so-called “profes- 
sional duties.” In the early days of trained nursing, 
when a nurse’s social status was not well understood, it 
may have been necessary to keep the question of dignity 


Pee A EE NURS ENG 157 


to the fore, to emphasize it on all possible occasions, and 
to be constantly on guard lest by doing this or that this 
dignity would be lowered, but it is not necessary any 
longer. A nurse who is a lady and has good common 
sense will not find herself embarrassed by doing any duty 
that presents itself. There is nothing that needs to be done 
jor the comfort of any patient which it rs beneath a nurse’s 
dignity to do. ‘That little point will bear repetition a 
good many times. A nurse can be just as dignified in 
washing dishes as in washing people’s faces; just as 
dignified in sweeping a room as in sweeping the crumbs 
out of a bed; just as dignified in giving some attention to 
the children in the home who are well, as in attending to 
children who are sick; just as dignified in getting a meal 
for herself or for others as in preparing nourishment for 
her own patient. It depends entirely on the circumstances 
in which she finds herself. If her “professional dignity” 
will not stand the strain to which she is going to be sub- 
jected as a nurse; if it is going to be a hindrance to her 
usefulness; if it helps to keep her idle or causes people to 
want to get her out of the home as soon as possible, she 
is certainly better without it, or, at least, without so much 
of it. Some of the very best and most highly respected 
nurses in the land have washed patients’ bedding, washed 
floors, washed clothing, cooked meals, attended stoves 
and furnaces, and acted as general house-mother when the 
mother of the family was laid aside by illness and there 
was no one else at hand to attend to these duties. The 
question as to what they washed did not affect the ques- 
tion of dignity or respect at all. ‘There is material for a 
whole lecture on this one phase of the question. 

Another lecture might be devoted to the equipment 


158 PRIVATE NURST M2 


which a nurse should provide and what may be improvised 
in homes to take the place of the appliances and conve- 
niences she has been accustomed to in hospitals. ‘The 
matter of economy of bed-linen is another phase of the 
subject that may wisely be elaborated. 

The question of responding to calls is one on which 
nurses have widely differing ideas and standards of con- 
duct. For the rank and file of nurses the policy adopted 
in this matter will weigh heavily in determining the 
amount of the balance that will appear to their credit on 
the bank account at the end of the year. Physicians have 
used this one point especially in deciding on a list of nurses 
whom they would employ on their cases. A nurse calls 
on a physician and leaves her professional card, signifies 
her willingness to respond to calls—any kind of cases. 
Later this physician has an urgent call, and in trying to 
secure a nurse meets with this kind of an experience: 
“Very sorry, doctor, but I never take children”; the next 
nurse does not care for a short case; the third never goes 
out of the city; the fourth does not care for contagious 
cases; the fifth wants to know if he will guarantee the 
payment; the sixth has made an engagement for the 
evening; the seventh has a headache and wants to know 
if tomorrow will do; the eighth never takes a short case 
under five dollars a day; the ninth has not her clean uni- 
forms home from the laundry; and the tenth is sorry, but 
she is expecting a friend to call, and anyway she does 
not care to nurse children. ‘This illustration is not at all 
overdrawn. As many as seventeen nurses have been 
called in trying to secure one for an emergency, and all 
these varied excuses are being offered to physicians every 
day. A physician who has met with such responses when 


PRIVATE NURS ONG 159 


he sent a call to a nurse is likely to reduce materially the 
list he will call on the next time he has need of one. 

This whole question of responses to calls, and when a 
nurse is justified in refusing a call, is a phase of the sub- 
ject on which nurses need instruction, just as plain and 
explicit, as on any other line. 

Another important point that should come in the lec- 
tures is regarding the keeping of appointments. A great 
many nurses seem to have very lax ideas on this matter. 
Questions of off-duty hours; of the relation to the other 
nurse who may be associated on the case; of the uniform, 
when it should, and should not, be worn; of arrangements 
regarding laundry; the adjustment of prices when nursing 
people of limited means; of when a nurse is justified in 
abandoning a case before its conclusion; of etiquette 
when nursing in hotels and public places—all suggest 
themselves as phases of the subject that should be included 
in a course of lectures on private nursing. 

A good method in teaching is to have one or two practi- 
eal problems in private nursing to give the class for con- 
sideration to be discussed at the next lecture or class. 
For instance: A nurse has made an engagement to nurse 
a maternity patient about the first week in October; no 
definite date is fixed when her services are to begin. The 
patient has stated that she will need her for two weeks. 
The last week in September the nurse receives a call to 
nurse a typhoid-fever case that will probably last from 
four to six weeks. Is she justified in taking the typhoid- 
fever case and giving up the other one? 

A typhoid-fever patient required the attention of a 
second nurse for about ten days. Then delirium subsided 
and convalescence began. But one nurse was needed. 


160 PRIVATE NURSES 


The family preferred the second nurse who was called, but 
feeling that the case rightfully belonged to the nurse who 
was called in the beginning, the second nurse was 
allowed to go. The day after the second nurse left the 
first nurse received a call to another typhoid-fever patient 
which promised to be a long case. She left the family 
without any nurse, left also a bundle of soiled clothing to 
be washed at the expense of the family and sent to her. 
Did she act honorably and squarely with that family? 

A physician calls a nurse to a case. In a few days the 
family become dissatisfied with the physician, dismiss 
him, and call another. The second physician criticizes 
past treatment and appears dissatisfied with the nurse’s 
methods. She knows he would prefer to have another 
nurse, but the family seem satisfied. What should she do? 

A nurse on a private case was given an order by the 
physician in charge to give a dose of a certain medicine. 
The order was written. ‘The nurse read the order and 
asked if she read it as he meant it, as she recognized 
that the dose ordered was above the maximum dose. 
The physician repeated the order verbally. The nurse 
felt she did not dare to suggest that it was an overdose. 
She gave the dose as ordered and the patient died from 
the effects of the drug. Was the nurse responsible ? 

When a nurse has notified a physician or a registry that 
she is “on call,” what restrictions does she thereby place 
on herself in regard to personal or social engagements or 
plans? 

These are practical questions which can be multiplied 
indefinitely by any teacher who knows much of the private 
nursing situation in America; they are questions that will 
be well worth giving to pupil nurses for consideration. 


VESTTING NURSING 161 


VISITING NURSING 

The field of visiting nursing is one which is certain to 
afford employment for an increasing number of nurses 
as the years go by. An erroneous idea has prevailed, 
both among nurses and the laity, that any one who had a 
kind heart and a knowledge of nursing was fitted to 
become a visitingnurse. Without any clear idea of what 
was involved in such work, nurses have taken it up “just 
for a change”; “because they wanted to be out-of-doors 
more”; “because they were tired of private nursing”; 
“to see if they would like it,” or for various other similar 
reasons. The association that employed them was ob- 
liged to teach them the very A B C of visiting nursing, or to 
turn them at large, if it was a new work, to find out, the 
best way they could, how to do what seemed to be ex- 
pected of them. After a few months the nurse discovers 
that she is in the wrong place, that she is in no sense of the 
word fitted to meet the demands on patience and persever- 
ance, wisdom and ingenuity, courage, human strength, 
and resourcefulness, and she drops out and another nurse 
offers herself who may be just as much confused as to the 
requirements, methods, and purposes of the work. This 
would not happen quite so frequently if training-schools 
placed seriously before their pupils the needs of such work 
and the kind of women who are fitted for it. No line of 
nursing calls for more superior qualifications than does 
visiting nursing. The visiting nurse has to deal not only 
with patients as seriously ill as those in hospitals, but she 
has to endure the added disadvantages of bad sanitary 
surroundings in many cases, the pinch of poverty, lack of 
conveniences, the prejudice and superstition of the ignorant 


162 VISITING NURSES 


poor, and very often to do her work surrounded by a group 
of curious neighbors. She must be able to meet emergen- 
cies of all kinds in these unfavorable surroundings, and so 
manage the situation that, in spite of drawbacks, the patient 
will have a good chance for recovery. She must be 
able, on short notice, to adapt her surgical technic to tene- 
ment-house operations, and out of the meager furnishings 
and appliances, in the midst of the dirty, unsanitary 
surroundings, prepare for an operation. During the opera- 
tion she may be the sole assistant to the physician, and 
have to assume duties which, in her training-school days, 
were divided between two or three others. She must 
not only be a skilled nurse, thoroughly familiar with the 
details of baths of all kinds and other hydrotherapeutic 
procedures, with treatments of every conceivable kind 
for chronic or acute medical cases, but must be equally 
skilled in the management of surgical, obstetric, and gyne- 
cologic patients. She must know how to readjust splints, 
extension and orthopedic apparatus, must have the art 
of bandaging at her fingers’ ends, must know also how 
to prepare an appetizing meal at small cost. She must 
know the charitable resources of the city, the functions 
and limitations of the different institutions and organiza- 
tions—not only those that deal with the sick, but must be 
familiar with helpful agencies of all kinds. She must 
have her faculties of observation highly trained, must 
know something of the laws of the city or community 
regarding sanitary matters. She requires infinite tact 
and judgment, not only in dealing with the poor, but with 
other workers in the field of charity. She needs, also, a 
certain amount of knowledge of the principles underlying 
scientific charity, though she herself is not expected to 
dispense alms except in case of dire necessity and emer- 


MESTITING NURSING 163 


gency. She is often required to act, not only in the capa- 
city of nurse, but must be nurse, probation officer, tene- 
ment-house inspector, financier, cook, and general mana~- 
ger of the poor man’s home and interests all at the same 
time. 

Inasmuch as her best work will be in helping and 
teaching how to prevent sickness, she must be “apt to 
teach”—must be able to bring intelligence to bear on 
ignorance, superstition, and prejudice, and patiently and 
kindly labor to bring about better standards of life and 
living in the homes which she enters. 

If pupil nurses can ‘be given a clear view of what visit- 
ing nursing means while they are in training, they will be 
less likely to rush thoughtlessly into it, to their own detri- 
ment often as well as to that of the poor whom they attempt 
to nurse. If, while in the hospital, they have the oppor- 
tunity to acquire a couple of months’ experience in the 
actual work, it will be a valuable period in their training. 
This opportunity is afforded in a number of hospital 
training-schools. Apart from the advantages to the nurses 
in giving them a wider outlook on life and a better knowl- 
edge of its problems, there are advantages from the 
hospital standpoint and a larger number of hospitals in 
future will, in all probability, discover these advantages. 

Tf the pupil nurses can be sent out under the direction 
of a supervisor till they have gotten over the first bewilder- 
ing and discouraging experience, it is certainly the best 
way. If this is impossible, there should be most explicit 
teaching before they are sent out, and they should be 
required to report at least twice a day at the hospital to 
some experienced nurse who understands the needs and 
is able to give advice and direction regarding the great 
variety of questions that arise. 


CHAPTER XVII 


Specimen Examination Papers 


DIETEDICS 

1. What do you consider the three most immediate 
necessaries of life ? 

2. Define food. From what sources do we obtain 
proteids, salts, fats? 

3. Why do you consider a mixed diet advisable ? 

4, What articles of food would you exclude from the 
general diet of an invalid that might be allowed to healthy 
people, and why? 

5. Give a list of foods that contribute material for—(qa) 
tissue-building; (b) force and heat. 

6. Explain the terms carbohydrate, protein, casein, 
gluten, myosin, albumin. 

7. Give a list of eight articles of food for a simple dinner, 
planned so as to include all the important food ingredients, 
and tell in which dish the greater amount of each is con- 
tained. 

8. What are the uses of—(a) water; (b) fruits, in the 
body ? 

9. How should tea be made, and what is its value as 
food ? 

10. What fluid food contains the most nutriment? 
Give four ways in which it may be served. How would 


you alter it in case of weak digestion ? 
164 


EXAMINATION PAPERS 165 


11. How should starchy foods be cooked ? 

12. Prepare a daily menu for a patient on a farinaceous 
diet. 

13. What are the chief ingredients of eggs? How 
would you prepare and serve a soft-boiled egg, a scrambled 
egg, albumin-water? State some conditions in which 
eggs should not be used. 

14. How would you prepare beef-broth, and what is 
its nutritive value ? 

15. Describe the proper method of preparing dry toast, 
coffee, and beefsteak for an invalid. 


PRACTICE OF NURSING 

1. What general care would you give a bed patient 
every day in the absence of orders? 

2. State the measures you would use to prevent—(a) 
bed-sores; (6) infection of a bladder by catheterization. 

3. What care would you give a typhoid-fever patient? 
Include in your answer general management of surround- 
ings and bed, excreta, mouth, diet, baths, and precau- 
tions against hemorrhage. 

4. How would you give a nutritive enema? Answer 
must be given in detail. 

5. What are the uses of the vaginal douche and how 
should it be given? What conditions modify its effects? 

6. Describe your method of administering a turpen- 
tine stupe, a cold pack, a mustard foot-bath. 

7. What precautions would you use in the administra- 
tion of medicines in general? What special precautions 
in giving sedatives? 

8. How would you—(a) dust a hospital ward? (b) dis- 


ND 
166 EXAMINATION PAPERS 


infect bed-pans and urinals? (c) disinfect a clinical ther- 
mometer while taking temperatures in a ward? (d) 
care for soft-rubber catheters after using? (e) care for a 
hypodermic syringe? 

9. What facts would you consider it necessary to find 
out about a new patient during the first six hours he was 
in your charge? 

10. Describe your method of giving a cleansing bath 
to a bed patient? 

11. If a maternity case had a chill, what would you 
suspect and what would you do? 

12. How would you place a patient in a Sims, dorsal, 
lithotomy, knee-chest position ? 

13. Describe your method of hand disinfection. 

14. What degrees of temperature would you consider 
alarming in a case of typhoid fever? 

15. State the simple measures you would use to check 
vomiting after anesthesia. 


BACTERIOLOGY 

1. Explain the terms bacteria, micro-organisms, sap- 
rophytes, parasites. 

2. Who was the first physician to ascribe to micro- 
organisms the power to produce disease ? 

3. Write short notes on the works of Pasteur, Lister, 
Koch, Eberth. 

4, What work is done by bacteria in nature? 

5. What conditions are necessary for the growth of 
pathogenic bacteria ? 

6. Name the channels by which disease-producing 
‘bacteria may enter the human system. 


EXAMINATION PAPERS 167 


7. What general precautions would you use in a hospi- 
tal ward to prevent infection ? 

8. Why do not all germs grow and multiply that gain 
an entrance to the human body? 

9. Name the germs commonly encountered in surgery. 

10. What do you understand by the terms “immunity,” 
“period of incubation,” “phagocytes” ? 

11. What do you understand by Koch’s circuit ? 

12. How are disease germs thrown off in the following 
diseases: Diphtheria, typhoid fever, tetanus, tuberculosis, 
yellow fever ? 

13. What conditions may modify the power of disinfec- 
tants? 

14. Describe a method of disinfecting the hands. 

15. How may infection reach a wound ? 


ANATOMY AND PHYSIOLOGY 

1. Define the terms physiology, anatomy, alimentary 
tract, lymphatics. What is a gland? 

2. Name the chief systems of organs, giving the names 
of the various organs in each system. 

3. What is the spinal canal? Describe the general 
arrangement of the ribs. 

4. Describe the composition of bone, the structure of 
muscle. What is a tendon? 

5. What are the functions of—(a) the blood; (6) of 
bile? What are the uses of water in the system ? 

6. What are the functions of the kidneys and bladder? 

7. Describe the skin. What are pores, sebaceous 
glands? 


168 EXAMINATION PAV 


8. Name the principal digestive fluids. What changes 
take place in the food when exposed to each fluid? 

9. Give a summary of the process of digestion. 

10. What is absorption? What parts of the body are 
concerned in it? 

11. Differentiate between lymph, chyle, and chyme. 

12. What is the function of the thoracic duct? Where 
is it? 

13. Describe the general structure of the brain. How 
is it protected ? 

14. Write short notes on waste and repair, the spinal 
cord, the nervous system, the liver. 

15. Next to water, what is the most abundant substance 
in the urine? 


MEDICINE AND MATERIA MEDICA 

1. State five ways in which medicines may be admin- 
istered. 

2. In the absence of definite orders, what rules would 
you observe regarding the time of giving medicine in its 
relation to food ? 

3. Name two drugs that cannot be dissolved in water. 
How would you give them? 

4, What special precautions are to be observed in giving 
medicine by hypodermic injection ? 

5. Give the average adult doses of the following: 
Tinctura ferri chloridi, sodium bromidi, chloral hydrate, 
nux vomica. What effects would you expect from each? 
How would you give them? 

6. Name three preparations of opium. What effects on 
respiration and secretions are produced ? 


Px awWINATILON PAPERS 169 


7. Name three drugs that are usually given after meals; 
three usually given before meals. 

8. What are the uses of mustard? 

9. Name three cathartics. State whether the action is 
mild or severe. How would you give them? 

10. What rules should govern nurses regarding the pre- 
scribing of drugs? 

11. If obliged to act in an emergency, what is the largest 
dose of the following that you would give: Morphin 
sulphate, strychnin sulphate, nitroglycerin, epsom salts? 

12. What drugs sometimes produce a rash? 

13. How would you calculate the dose for a child ? 

14. Name three drugs that may be given by inhalation. 
How would you provide medicated steam for a case of 
croup ? 

15. What do you mean by “anesthetic,” ‘“diaphoretic,” 
“sedative” ? 


SYMPTOMATOLOGY 


1. What do you understand by the terms objective and 
subjective as applied to symptoms? 

2. Give a definition of pain. Explain the terms reflex, 
spasmodic, paroxysmal, as applied to pain. Describe 
the kind of pain you would expect in the formation of an 
abscess in the breast. 

3. (a) What degree of temperature would you consider 
alarming? (b) If a sudden drop in temperature occurred 
in a typhoid-fever case, what would you suspect and what 
would you do? (c) What in a recent operative case? 

4. What are the prominent symptoms of inflammation ? 

5. In nursing a pneumonia case what symptoms would 
you regard as favorable? What as unfavorable? 


170 EXAMINATION PA PERE 


6. What conditions have a modifying effect on disease 
and its manifestations ? 

7. In a critical inspection of a patient, what points 
would you note? 

8. (a) If the eyelids are swollen and puffy, what organs 
would you suspect were affected and what results would 
you fear? (b) If this condition occurred in a pregnant 
woman, what cause would you suspect, and how would you 
investigate ? 

9. What organic disease would you suspect if a patient 
were found frequently cyanosed ? 

10. Write a short paper on the skin, describing its 
appearance in health, and some conspicuous changes 
that take place in it in certain diseases. 

11. Of what diseases may chills be a premonitory symp- 
tom? 

12. In taking charge of a new patient, what points 
would you note about mental condition, facial expression, 
eyes, lips, mouth, tongue ? 

13. What observation would you make regarding cough 
and sputum in a case of supposed incipient tuberculosis ? 
What in a more advanced stage? 

14. What position in bed would a patient naturally 
assume in peritonitis, colic, pneumonia of the right lung? 

15. What may a nurse observe that will be of value in 
determining the condition of digestive organs? 


\ SURGICAL NURSING 
1. What do you understand by the terms surgery, dislo- 
cation, sprain? What simple treatment would you use 
for the latter? 


Pon NAT TON PAP E Ros 171 


2. In the absence of definite orders, how would you 
prepare a patient for hysterectomy ? 

3. Describe your method of managing shock if left to 
your own resources. 

4. State the symptoms of internal hemorrhage. What 
would you do in such a case, after laparotomy ? 

5. What precautions would you observe in nursing a 
case of empyema after operation ? 

6. In caring for a patient after nephrorrhaphy, what 
special precautions would you use? 

7. What symptoms would you particularly notice in 
the first three days after an operation for intussusception ? 

8. How would you prepare for intravenous infusion ? 
What physiologic effects would you expect it to produce? 

9. Define the terms ligature, suture, drainage-tube. 
Name one substance used for each, and state how it should 
be prepared for use. 

10. Describe your method of sterilizing rubber gloves and 
the care after use. 

11. What articles would you provide for the use of the 
anesthetist during an abdominal section ? 

12. What instruments would you prepare for an opera- 
tion for strangulated hernia ? 

13. How would you prepare the following solutions: 
carbolic acid, 5 per cent.; lysol, 4 per cent.; creolin, 3 per 
cent. ? 

14. What conditions may cause a rise of temperature 
after operation ? 

15. Prepare a paper, not exceeding 500 words, on the 
complications of wounds. 


172 EXAMINATION PARES 


GYNECOLOGY 

1. What are the principal organs and structures con- 
cerned in gynecology? Locate the internal organs of 
generation with relation to each other. 

2. State the functions of the uterus, ovaries, Fallopian 
tubes. | 

3. Define the terms puberty, menstruation, menopause, 
cyst, vagina, vulvitis, amenorrhea. 

4, What physical changes take place at puberty in the 
female ? 

5. What do you understand by subinvolution of the 
uterus and what may cause it? 

6. What advice would you give a woman regarding her 
method of managing a vaginal douche in the home? 

7. How would you prepare gauze strips for packing the 
uterus and how long are these usually left in place? 

8. What diseases or displacements frequently follow 
laceration of the perineum, and how may these affect the 
general health? 

9. Name the early signs of cancer of the uterus. 

10. How would you care for a patient after perineor- 
rhaphy ? after Alexander’s operation ? ; 

11. Write a short paper on gonorrhea in the female, 
stating causes, symptoms, parts involved, precautions 
to be used. 

12. Name six causes that may result in amenorrhea. 

13. In case of threatened abortion, what preventive 
measures would you use? 

14. What are tampons? pessaries? Why are they 
used? How would you prepare each for use? 

15. How would you prepare a gynecologic patient for 


EXAMINATION PAPERS 173 


a non-instrumental examination, abdominal and vaginal? 
How would you assist the physician in an instrumental 
vaginal examination ? 


OBSTETRICS 

1. What advice along hygienic lines would you give 
to a pregnant woman? 

2. State the symptoms you would expect to find in a 
case of pregnancy at the end of the third month. 

3. Explain what is meant by the term normal labor. 
How may a nurse tell that labor has begun? Explain 
the meaning of “stages of labor,” and tell when each stage 
begins and ends. 

4. When should ergot not be used? When is it usually 
used ? 

5. How would you prepare the patient and the room for 
delivery ? 

6. What simple measures may a nurse use to lessen the 
patient’s discomfort during the early stages of labor? 

7. In the absence of a physician, how would you manage 
a case of normal labor? 

8. How would you deal with a case of postpartum hem- 
orrhage ? 

9. What instruments would you prepare for a perin- 
eorrhaphy ? 

10. What measures would you use in case of asphyxia 
in the infant? 

11. How would you endeavor to prevent fissure of the 
nipples? What care would you give after the fissure had 
formed ? 

12. Through what channels, and from what causes, 
may puerperal infection occur? 


174 EXAMINATION PAPERS 


13. State the common causes, symptoms, and preven- 
tive measures of mastitis. 

14. What special preparation would you make in a case 
of premature birth and how would you manage the prem- 
ature infant during the first week ? 

15. Prepare a bill of fare for the first four days follow- 
ing confinement. 


URINARY DISEASES AND URINALYSIS 

1. Locate the kidneys, ureters, bladder. 

2. What is the average quantity of urine passed in 
twenty-four hours by the normal adult? What condi- 
tions in health may modify this amount? 

3. Explain the terms “suppression” and “retention” 
as applied to urine. 

4, If retention occurred in an obstetric patient following 
delivery, what measures would you adopt to relieve be- 
fore resorting to catheterization ? 

5. Why is it necessary to measure urine preceding and 
following a surgical operation under general anesthesia ? 

6. What changes would you expect to find in the urine 
voided in the first forty-eight hours after laparotomy, and 
why? 

7. Define cystitis. How may it be caused and avoided? 

8. Describe your method of catheterization. 

9. How would you irrigate the bladder? how prepare a 
specimen of urine for analysis? 

10. What changes are likely to occur as regards quantity 
in the urine in the early stages of acute fevers, hysteria, 
alcoholism ? 

11. Explain what you mean by specific gravity. What 


ES ANMENATILON:/ PAPERS 175 


is the normal specific gravity of urine, and how may it be 
determined ? 

12. What symptoms in a pregnant woman would lead 
you to suspect albumin in the urine? 

13. Give two methods of testing for albumin. 

14. Explain why it is sometimes necessary to catheterize 
a patient even when urine is frequently passed. 

15. What general symptoms would you expect to find 
in a case of uremia? 


HYDROTHERAPY AND MASSAGE 

1. What general effects would you expect to follow 
from copious drinking of pure water? 

2. What effects may be produced on temperature by 
external applications of water? What conditions modify 
these effects ? 

3. Describe two methods of using water for its sedative 
effects. 

4. What physiologic effects would you expect from the | 
injection of salt solution by hypodermoclysis? What 
advantage has this method of injection over the rectal 
method ? 

5. How would you give the following treatments: 
lavage, enteroclysis, vapor bath to a bed patient, sitz- 
’ bath, Scotch douche to a patient with synovitis in a pri- 
vate house ? 

6. How would you sponge a fever patient to reduce 
temperature ? 

7. Describe your method of giving a hot pack in a 
case of uremia. 

8. How would you give a bath for its tonic effect ? 


176 EXAMINATION PAPERS 


9. At what temperature would you use the water for a 
hot full bath? How would you manage it, and what 
general effects would you expect it to have? 

10. How would you apply a cold wet-sheet pack to a 
typhoid-fever patient? also a wet-sheet rub in case of 
general debility ? 

11. Explain what you mean by the term “massage.” 

12. What is the aim in using the stroking movement? 
What from friction and kneading ? 

13. Describe your method of giving massage for syno- 
vitis ? - 

14. Name three conditions in which massage is contra- 
indicated. 

15. How would you give a general massage, and what 
effects would you expect the treatment to produce? 


DISEASES OF CHILDREN 

1. What is the rate of pulse and respiration in the 
normal infant, and what conditions modify these rates? 

2. What causes may produce variations in the tempera- 
ture of an infant? What would you consider a patho- 
logic temperature in a week-old infant ? 

3. What substance is lacking in the saliva of a new-born 
infant, and when may this substance be expected to be 
present ? 

4, State the average capacity of an infant’s stomach 
at birth. Show why regularity in feeding is important. 
5. Describe the feces and urine of the normal baby. 

6. What is the best test of the suitability of the baby’s 
food ? 


EXAMINA TION) PAP BARS ERE 


7. If the food is defective in quality, how would you 
expect it to affect the child? 

8. What measures would you use to improve the quality 
and increase the quantity of the mother’s milk? 

9. Explain the term “marasmus,” and give its symp- 
toms and prophylaxis. 

10. What are the chief causes of the summer diarrhea 
of infants? What advice would you give a mother with 
a view to its prevention ? 

11. In the absence of a physician’s orders, what sim- 
ple measures would you use in the care of a case of infan- 
tile diarrhea ? 

12. How would you manage a case of spasmodic croup, 
also convulsions, in a two-year-old child ? 

13. What preventive and curative measures would you 
advise a mother to use in regard to thrush? 

14. How would you manage a case of measles ? 

15. Write a paper of about 400 words on constipation 
in infants. 


DISEASES OF THE NERVOUS SYSTEM 

1. Describe briefly the nervous system. 

2. What are the functions of the spinal cord? _ 

3. What are the general causes of diseases of the ner- 
vous system ? | 

4, Show why diseases of the nervous system often inter- 
fere with the normal action of other organs, and give 
examples. 

5. Explain what you mean by the terms neuritis, 
grand mal, petit mal, catalepsy. 

6. What hygienic measures would you advise in a mild 


case of chorea? 
12 


178 EXAMINATION PAPE Rss 


7. What simple measures would you use to prevent 
and relieve wakefulness in children ? 

8. Explain what you mean by the term neurasthenia. 
What symptoms would lead you to suspect the condition ? 

9. Describe Weir Mitchell’s rest treatment. 

10. Outline a course of non-medical treatment for the 
relief of insomnia. 

11. What do you understand by the terms illusion, 
delusion, incoherence, acute mania, dementia, melancho- 
lia? 

12. Name some common causes that are believed to 
produce temporary insanity. ! 

13. Write a short description of a case of hysteria which 
you have nursed, giving the general characteristics, and 
outlining the methods of treatment used. 

14. What precautions would you observe in nursing 
a case of apoplexy in which coma was present ? 

15. What advice would you give along hygienic lines 
to a person afflicted with migraine? 


THE HEAD NURSE 


CHAPTER XVIII 


The Head Nurse 


If it be true that good nurses are born, not made, it is 
preéminently true of head nurses—those nurses who, 
having become proficient in the art of nursing and demon- 
strated their fitness for leadership, have had committed 
to their immediate charge a certain section or department 
of a hospital and the direction of other nurses. 

The nurse who undertakes this responsibility and 
successfully measures up to it must possess not only the 
qualifications that are combined in a greater or less degree 
in good nurses in general, such as tact, patience, discreet- 
ness of speech, love for her work, neatness, dignity, self- 
control, but must have, in addition, the executive force 
needed to plan for others and direct, must have a womanly 
sweetness combined with strength, a gentleness backed 
by will force, must have an infinite capacity for. details, 
must be able to rebuke without arousing antagonism, must 
have a genuine poise of soul that will enable her to meet 
with sweetness and courage the emergencies that are 
constantly arising in a hospital having an active service. 

The head nurse carries a fourfold responsibility. She 
owes to the hospital with which she has identified herself 
her allegiance to its highest interests. She owes to its 
authorities respect, to her associates in service the courtesy 
demanded of a lady. She owes to the institution the pre- 


servation of a discreet silence regarding its internal affairs, 
181 


a rs 


YY * 


182 THE HEAD NOE 


such protection of its interests as her position enables her 
to give, no matter how antiquated, inefficient, or imade- 
quate she believes its service to be. If she wishes to intro- 
duce change in method, she owes it to those who, in the 
final resort, carry the responsibility, to consult them before 
attempting to instruct those over whom she has authority 
to deviate from the methods in vogue. 

She owes to the physicians, who stand in the relation of 
superior officers, her respectful adherence to their orders, 
and, as far as may be, to their wishes and preferences. 
She owes to each physician her loyalty—not loyalty to 
Dr. Jones and an utter disregard of Dr. Brown’s interest. 
She can often, by a sentence, or even a shake of the head 
at the right time, undermine a patient’s confidence in Dr. 
Jones, but she has no right to do it, even though she does 
not like the man nor approve of his methods. She owes 
to the attending physicians absolute silence regarding their 
professional demerits or blunders. 

She owes to the nurses whose work and conduct she 
directs a careful attention to the details of their service, 
a.study of their individual characteristics, an intelligent 
use of all the means at her disposal, that will aid in their 
development as nurses, and an example that will be safe 
for them to follow. 

What the head nurses of a hospital are we may expect 

/ the pupil nurses to be. This is one fact that needs espe- 
cially to be borne in mind when choosing nurses for such 
places of responsibility. If the head nurses are lacking 
in dignity, free and familiar in their. relations with physi- 
cians, harsh or unsympathetic in their bearing toward 
the patients, we may expect to see the same qualities 
expressed in the daily lives of the nurses. It is not alone 


—ccems 


a 


ae HEAD NURS £ 183 


a question of professional or executive ability; not alone 
what she can do, but what she is, that counts. 

No nurse who has not learned the lesson of implicit 
obedience to_authority, and practised it till it has become 
a habit of life, is fitted to command others. In a hospital, 
perhaps more than in most institutions, it is necessary for 
military discipline, military precision, military obedience, 
to prevail. This is one of the hard lessons for many 
head nurses to learn. It is difficult for them to measure 
accurately the degree of their influence upon others. 
Instead of creating in their subordinates a respect for 
authority, they manage to stir up questionings and doubts 
in the minds of pupil nurses as to the wisdom of this or 
that ruling. This is perhaps not often intentionally done, 
but, intentional or otherwise, the results are the same. 
The human tongue everywhere is capable of creating 
trouble unless controlled by principle, and the head nurse 
is in a good position both to create and to quell institu- 
tional disturbances. 

The vital point at which many an otherwise capable 
head nurse fails is in the fact that she fails to see her 
place in the institutional situation clearly. She neither 
grasps its possibilities nor observes its limitations. It 
ought not to be necessary to remind a head nurse that she 
is not the superintendent, and that, above all, there must 
be one final authority whose methods must be followed 
and whose will must be law, if order is to be preserved, 
but this fact is frequently overlooked. This phase of the 
head nurse problem makes itself keenly felt where are 
grouped in the same hospital several head nurses who 
are graduates of different schools. Each believes her 
methods superior to those of the other nurses, and practises 


184 TEE HEA DINU Rea 


them. If a steady, firm discipline is not maintained 
throughout the whole institution, confusion is sure to 
result. ‘The pupil nurses, if taught by one head nurse 
that a thing must be done this way, by a second that way, 
and by a third a totally different way, soon become care- 
less and think that “any old way will do,” and who can 
blame them? ‘This tendency among head nurses consti- 
tutes today one of the largest of the every-day problems 
of the superintendent. It is this one phase of the modern 
head nurse that leads many a superintendent to choose 
heads of departments exclusively from those trained in 
the institution, often to the detriment of the institution. 
There is no one hospital whose way of doing everything 
is the best known. The infusion of new ideas and new 
methods is desirable and cannot but be helpful, if it can 
be accomplished in the right way, after due consideration 
on the part of those in authority, and made a uniform 
practice throughout the institution. 

Another great difficulty with many otherwise capable 
head nurses is their inability to see the needs of the institu- 
tion as a whole. They become so engrossed with their 
own department that they allow themselves to get out of 
touch with other departments and with the general work 
of the hospital. If emergencies in other departments are 
allowed to affect them; if they are asked to spare a nurse 
temporarily to meet some unusual need in some other 
department, they forthwith feel that an injustice has been 
done them, and they cherish a personal grievance against 
the superintendent. This is no imaginary difficulty. 
It is all too deplorably real, and is making the problem 
of training-school discipline tremendously more difficult 
in many a hospital. It is often stated that one cannot 


Dt Eo EA DN OR SE 185 


expect to get all the virtues combined in one person, but 
the virtue of unselfishness, of devotion to the interests 
of the institution as a whole, of justice and every-day 
kindness, should not be left out of reckoning when con- 
sidering candidates for heads of departments. No nurse 
who gives unpleasant exhibitions of temper, or who feels 
that she is abused when asked to rearrange her plans, is 
fitted either to be intrusted with the care of a number of 
_ sick people or to command pupil nurses. An unwilling, 
selfish spirit, a spirit that rebels when called upon to 
meet the emergencies of hospital life, is not the spirit for 
successful leadership. 

The head nurse should never be chosen from the class 
of nurses—unfortunately, a very large one—that con- 
siders a nursing education finished at graduation. The 
head nurse who never studies will soon find herself out- 
distanced by the bright nurses in training over whom she 
is placed. None are quicker to note narrowness and limi- 
tations and lack of ambition than students, and the nurse 
who has no taste or inclination for study will find it a 
difficult matter to retain the respect of subordinates. 
It is true that the distractions of hospital work and the 
responsibilities of the life are not conducive to systematic 
habits of study, but if head nurses are to become efficient 
teachers and leaders, they must take time to plan and 
prepare; they must have a general knowledge of what 
is being taught by others. 

Further than this, the head nurse needs to study people } 
every hour of every day to understand human weaknesses } 
and motives, conditions and habits, if she is to be, in | 


' 


deed and in truth, mistress of the situation, ’ 


CHAPTER XIX 


The Head Nurse and Her Patients 


In the relation of the head nurse to the patients there 
is afforded ample scope for the practice of many of the 
highest womanly virtues. Not only will her attitude 
toward them have a decided bearing on the comfort of 
the sick, but her example and influence on the pupil nurses 
will be far-reaching in its effects. ‘To the patients, and 
to the general public, the head nurse stands in the relation 
of hostess, and from her will be expected the same courtesy, 
the same thought for the comfort of her household, as 
would be given by a lady to a guest in her private home. 
In the manner of receiving patients there is room for 
improvement in many hospitals. Head nurses can help 
much by rightly impressing patients and their friends at 
the very beginning of their hospital experience; by show- 
ing them in numberless indefinable ways that the institu- 
tion is a place in which the Golden Rule is practised; 
by teaching the nurses of whom they are in command to’ 
give special attention to the latest arrival—the bewildered, 
depressed stranger in their midst. Too often the entrance 
of a patient is a most mechanic performance. 'To the 
nurse, she is one more individual in the never-ending pro- 
cession passing through the halls of pain, one more patient 
to write orders for, one more on the diet-list, one more 
bed filled or one more room occupied—that is all. To 


the patient it is one of the momentous experiences of life, 
186 


BR RA) BENE aS 187 


an experience dreaded, protested against as long as pro- 
tests availed. Preceding the coming to the hospital has 
been, probably, the parting from friends, visions of dread- 
ful possibilities, the shrinking from committing himself 
to strange hands. But to the nurses he is simply “a 
case,” qualified in some instances by the word “accident” 
or “fever,” or by the name of the attending physician, as 
“Dr. A.’s new case’ or “Dr. B.’s operative case.” But 
whatever the qualifying term used, the patient is a ‘‘case,” 
his individuality or his state of mind at that time appa- 
rently being of very little consequence. 

A few sympathetic reassuring words would mean more 
at that particular moment perhaps than at any other 
time in his life, but if the head nurse is too busy to speak 
them, if she has not trained her nurses to think of them, 
they will not be spoken. It is not enough that she teach ° 
nurses that the clothing of a new patient must be listed 
and put away, that his temperature must be taken and 
a bath given at the earliest opportunity; she ought to 
remember to put herself in the stranger’s place, to teach 
her nurses that to allay the unspoken questionings and | 
fears is as important as the mechanic work to be performed | 
for the patient, and can be done quite naturally in con- | 
nection with it. To tell a patient at the trying period 
of entrance, for instance, that nearly everybody who 
comes here gets well; that every one will do everything ~ 
possible to insure a good recovery; that he will like the 
hospital when he gets over the strange feeling, may mean 
the difference between peace of mind and mental distress. 
The neglect of such details does not always mean an 
absence of kindly feeling, but rather a thoughtlessness 
on the part of the head nurse that is deplorable. The 


188 HE R PAM Eas 


very existence of the hospital reflects the desire of its 
founders and supporters and trustees to minister to human 
distress and bring comfort to the sick. It remains for 
the head nurse to interpret, in the truest manner possible, 
the real spirit of the institution. ‘To neglect it, is to show 
clearly that she has a very imperfect understanding of 
the patients and their human needs. 

It is needless to say that a firm, kind manner, a quiet 
dignity, must be maintained in all the intercourse with 
the patients. ‘There is a tendency on the part of some 
pupil nurses who are by nature more talkative than others 
to talk more than is desirable to patients, to “visit” with 
them, and neglect other important and pressing duties.. 
This tendency needs to be carefully watched and checked 
wherever manifested. A bright, cheerful, tactful, happy 
manner with patients is greatly to be desired in all nurses, 
but there is a danger, always present, of thoughtless 
nurses neglecting to notice the border-line between cheer- 
fulness and familiarity, or mistaking when their duty to 
one patient ends and their duty to another begins. One 
of the common failings of pupil. nurses is to neglect an- 
swering a call from one patient because they happen to 
be busy with another. There are, perhaps, few things 
which are more frequently complained of in hospitals 
than the neglect to answer bells, and nurses in general 
are only too prone to excuse themselves on plea of being 

/“busy.” An important part of their training ought to be 
the development of their ability to attend properly to the 
wants of a number of patients and keep all satisfied, 
to be busy with one and not neglect the other. ‘There are _ 
nurses, hosts of them, who will be a success if given one 
patient, and a failure, or nearly so, if given two or three. 


Sh gh aaah! tered ence. jituat® poi Joey ym 
Ural gir Vruey" a7 art LALCitee zed/ 
Pre Mee Se ie ys Po ee asl rte. Ly, 


Mn PARLE NES 189 


Much, however, can be done by training in developing 
ability along this line, a line on which the good reputation 
of a hospital frequently suffers. Who is there that is not 
familiar with the time-worn complaint of the patient who 
rang his bell for a half-hour, more or less, for a drink 
of water and then had to go without it? That very cir- 
cumstance, trivial as it may seem to the nurse, weighs 
powerfully against the patient’s friend coming to the 
hospital when a need arises. 

Apart entirely from the discharge of the professional 
duties, or the treatments for individual patients, abundant 
opportunity is afforded for the head nurse to touch help- . 
fully the inner lives of the patients. It may safely be 
inferred that many an adult comes to the hospital bringing 
with him, in addition to the physical disease, a burden of 
anxiety which may often be lightened by tactful manage- 
ment. A head nurse who knows how to listen helpfully 
to the recital of the troubles of her patients has gone a long 
way toward gaining the confidence without which no 
head nurse can do the best for a patient. While many 
sick people make heavy demands on a nurse’s stock of 
patience, the same is true, and perhaps in a greater degree, 
of the patient’s friends. With them, as with the patient, 
much may be gained by establishing proper relations 
at the beginning, and by a little tactful attention at the 
right time gaining their confidence. From them valuable 
information bearing on the patient’s condition or pecu- 
liar tastes may be secured. If the head nurse can succeed 
in getting a patient’s friends to come to her with any 
complaint or grievance, instead of carrying the tales of 
trouble to the office, or pouring them into the physician’s 
ear, or recounting them to friends outside, she has earned 


190 * RER PATOUE Noe 


the gratitude of several people. This she will rarely 
succeed in doing unless she takes pains, on the entrance 
of a patient, to impress the friends with her genuine interest 
in, and sympathy for, the subject of their particular 
solicitude. If the neglect complained of is real, the 
patient’s friends should be assured that all possible pre- 
cautions against its recurrence will be taken and that 
real neglect will not be tolerated. If explanations are 
to be made, the head nurse is the person to make them. 
In nine cases out of ten a tactful head nurse can adjust 


' the patient’s difficulties better than any other person, 


since she is in immediate command of the situation, and 
it is presumed thoroughly understands it. To remove 
all ground of complaint and keep things running smoothly, 
with easily ruffled, petted, or unreasonable people, calls 
for a fine display of tact and resourcefulness. 

There is another point in dealing with a patient’s friends 
that needs to be handled sensibly, sympathetically, and 
carefully—a point in which much will depend on the 
nurse’s judgment. ‘To say that a disease is to have a 
fatal termination, that the end is rapidly approaching, 
and that the patient’s friends should be notified, may 
not be her sole responsibility, but it is one which she must 
share. She is the person who will perhaps be the first 
to notice alarming symptoms, and while the raising of 
unnecessary alarm should be guarded against, it is infi- 
nitely better to summon the friends unnecessarily than 
to have the end come without having notified them that it 
was expected. This will happen in the best regulated 
hospitals sometimes. Sudden changes will come that 
are as much a surprise to the people in the hospital as to 
the friends outside; but no failure of the hospital is criti- 


HERG PR AEE NY iis Hs) 191 


cized more than the neglect of this one point of duty. 
It is one of the hardest things to forgive, and will rarely 
be forgotten if it is forgiven. It will be told and retold 
in an attempt to prejudice others against the hospital 
long after the patient’s name is forgotten in the institution. 

Another delicate matter with which head nurses will often 
have to deal is the incompatibilities of disposition which 
arise between patients and nurses. When a patient takes 
a strong dislike to a nurse, it is, as a rule, no use to reason 
with him. Some adjustment must be made. It may 
seem an injustice to the nurse to remove her when she is 
apparently honestly doing her duty and trying to satisfy, 
but in reality it is a greater injustice to keep her in charge 
of a patient who, because of his dislike, will certainly 
misrepresent her, and if he is in a ward, will incite others 
to complain. Incompatibilities of temper and disposition 
occur very frequently even with people in health and 
with individuals who have much to divert their attention. 
It is, therefore, not to be wondered at that they frequently 
occur with the sick, with whom mistaken magnitudes 
are very common. It is never a good plan to argue with 
the patient who has taken a dislike to a nurse or who 
frequently complains of her, or to try to convince him 
that his grievances are imaginary. ‘Then he will be cer- 
tain that he has at least one real grievance, and that the 
head nurse has no sympathy with him. Let him under- 
stand that it is taken for granted that there has been 
ground for complaint, that the matter will be looked 
into and corrected. There are ungrateful, unappreciative 
people, and will be till the end of time—people who would 
try the patience of an angel. ‘There will be nurses, while 
hospitals last, who will give cause for complaint wherever 


192 HER PATIENTS 


they may be placed, while at the same time they may 
commit no flagrant misdemeanors and may do fairly well 
with some patients. Many disagreeable patients ought 
to be firmly dealt with by the head nurse, and often the 
mere calling their attention to their unreasonable demands, 
or to their conduct, will work a happy change for all con- 
cerned. 

In a general hospital where no distinctions are made 
because of creed or color, situations calling for a high 
degree of tact and good judgment will sometimes arise 
when the question of creed or color has to be met. No 
woman with strong racial prejudices is well fitted for in- 
stitutional life. A broad, general sympathy with theaims 
and objects of the institution, and with the entire class of 
patients for whom it was designed, is an important requi- 
site in a head nurse. | 

The religious beliefs of patients are subjects with which 
no head nurse has a right to interfere, nor should any 
levity regarding the forms and ceremonies used by any 
sect be permitted among nurses. Complications regard- 
ing diets prescribed or forbidden by certain sects will 
occur, and must be met with abroad sympathy and toler- — 
ance. Few things will arouse more gratitude on the part 
of a patient than a practical expression of sympathy 
with his religious beliefs when he knew the nurse was not of 
the same belief. It is undoubtedly trying to have a patient’s 
breakfast postponed till a certain rite has been adminis- 
tered; it is trying to admit clergymen at unseemly hours 
when perhaps the morning sweeping is in progress, or 
treatments of various kinds are going on. But we are 
not in the business merely to please ourselves, and when 
such things do occur, they must be met with courtesy 


Tee? Poy En oN ps 193 


and patience and ready assistance. Such occasions to a 
patient in a hospital mean more than we can readily 
realize. 

The daily life in a hospital affords unexcelled opportu- 
nities for the study of character. If it be true that “the 
proper study of mankind is man,” then the head nurse 
has certainly a splendid opportunity to engage in proper 
study. 


13 


CHAPTER XxX 


Hospital Ethics and Discipline 


From the time a nurse begins her career as a proba- 
tioner in the training-school she should be given a clear 
understanding as to her relations to the institution, to its 
various officers, to nurses, and to servants. A copy of 
the rules regarding nurses should be furnished her, and 
any necessary explanations should be made at that time. 
This the institution owes to every probationer, but too 
often it happens that she is expected to learn rules by 
breaking them, or to get hold of them through the uncer- 
tainties of tradition. When a nurse has been told the rules, 
it is the business of the head nurse to see that they are 
enforced as far as relates to her department, and to coéper- 
ate with the superintendent in the maintenance of disci- 
pline. 

It need hardly be stated that the head nurse herself 
should strictly observe the rules of the hospital, which are 
made with the good of all concerned in view; but, as a 
matter of fact, many head nurses are anything but good 
examples in this respect. Too many head nurses are a 
law unto themselves; too many of them resemble Kipling’s 
heathen, of whom it was said: “’E don’t obey no orders 
‘less they is his own,” a most undesirable characteristic 
even in heathens. When it is found in a head nurse it bodes 
no good to the institution. If the house rules say “Lights 


in patients’ rooms must be extinguished by 9 P. M.,” 
194 


Mos Pit AL, EP ves 195 


that “nurses must not visit in the hospital proper while 
off duty,” and the head nurse is found visiting in a patient’s 
room at 10 o’clock at night, it is very likely the pupil 
nurses will soon get the impression that rules are not of 
much importance—not expected to be observed. 

If the rules say that nurses must confine their conversa- 
tion with internes to strictly professional subjects, must 
avoid all unnecessary conversation while on duty, and the 
head nurse sits at her desk and gossips about things in 
general for an hour at a time, how can pupil nurses be ex- 
pected to have due respect for institutional regulations ? 

It has been said that discipline is the difference between 
an army and a mob. If even a measure of discipline is 
to be maintained, head nurses must be impressed with 
the necessity of teaching, both by precept and example, 
that rules are to be observed; that if, for any reason, it 
becomes necessary for a nurse to deviate from them, 
explanations or apologies are in order. 

On the report of the head nurse will depend largely 
the acceptance or the rejection of the probationer, since 
she is in a measure responsible for her work and conduct, 
and is especially well situated to observe whether or not 
the candidate has in her the qualities necessary for a suc- 
cessful nursing career. Just here a word as to the need 
of patience with the probationer is in order. There are 
in our hospitals many head nurses who are in themselves 
capable workers, but who are utterly unable to see the 
promise or the possibility in a probationer who is slow in 
developing. With them either a probationer is a “jewel,” 
or she is “good for nothing.” There is no middle ground 
with them. They lack the power of seeing beneath the 
surface, of perceiving the diamond in the rough. Many 


196 HOSPITALIE Th 


a nurse who has, later on, proved to be a tower of strength 
to institutions and to homes, an assistant most acceptable 
to physicians, and a true friend to the sick, has in the be- 
ginning been most unjustly dealt with because some — 
head nurse did not see the use of bothering with her and 
reported adversely concerning her. ‘Then, too, very fre- 
quently a nurse who has seemed to be a failure under 
the direction of one head nurse has done acceptable work 
when placed under the supervision of another. As a 
rule, the probationer who is slow in developing will be 
more likely to succeed in a small training-school, where 
she comes into closer touch with the superintendent; 
where there is greater opportunity to study individuals, 
and where the sterling qualities are not lost sight of, or 
obscured, by the brilliancy of some brighter candidates 
who do not always continue to shine so brightly when 
they get further on. | 

In the daily practice in the wards the head nurse will 
‘find abundant opportunity for teaching ethics, the branch 
‘of science which treats of human actions from the stand- 
| point of right or wrong. In the past it must be admitted 
that much more stress has been laid on hospital etiquette 
_than on ethics. Both are important, but a thorough 
) understanding of hospital ethics will make it very much 
‘easier to teach the simple form of conduct or manners 
applicable to certain places or occasions. 

After years of experience with nurses it has come to be a 
habit with at least one superintendent to emphasize first, 
in the theoretic teaching of ethics, the point of common 
honesty—“‘truth in the inward parts.” And the simple 
practice of common honesty in a hospital every day will 
carry us far. ‘Too many of our nurses come to the hospi- 


BeOrsat IT AE. EY Pees 197 


tal with poorly developed consciences, or, as a popular 
writer has termed it, “fatty degeneration of the con- 
science.” Whatever term is used, the fact is plainly in 
evidence that the matter of conscience-building has 
received scant attention in the homes from which some 
of our nurses have come. Perhaps it is true that many 
things are done from pure thoughtlessness, but there 
are times when thoughtlessness is criminal, and other times 
when it is positively inexcusable. 

Accustomed to the freedom of a home, some nurses 
quickly forget that they are stewards of hospital supplies, 
that things intrusted to them for the use of patients are 
not personal property to be used or abused at will. There 
is a principle involved in the smallest transaction, but the 
principle will often be overlooked unless it is pointed out. 
Here the head nurse has a splendid opportunity to raise 
the whole moral tone of the hospital through her intimate 
contact with the nurses and by her own personal example. 

The simple practice of the homely virtue of honesty 


So, 


will compel a nurse to own up when the breakage or des- | 


truction of an article occurs, but, unfortunately, the rule 


in many hospitals is that “nobody did it.” 

__ The practice of every-day honesty will keep a nurse from 
sneaking an egg out of the ward refrigerator over to her 
room to use in shampooing her hair. It will prevent her 
nibbling at the plate of fruit in the ice-box that belongs 
to some patient. It will keep her from appropriating 
for her own use articles of food or special delicacies pro- 
vided for patients. These are homely illustrations of 
ethical questions, but any one who has lived in a hospital 
must admit that they are true to life; so true that some 
hospitals have had a special rule punishing with dismissal 


198 HOS Pil T.A LV EY? tae 


any nurse found guilty of taking for her own use fruits 
belonging to patients or delicacies provided by the hospital 
for them. 

The practice of honesty will compel a nurse to own up 
when she fell asleep on night duty, or when she kept her 
light burning after hours or came in late. The agree- 
ment on the nurse’s part to keep the rules made when she 
applied or was accepted is very often quickly forgotten. 
There is no denying that the practice of simple honesty 
applied to every-day conduct will be far-reaching. 

Next in the points to emphasize in the teaching of 
ethics might be mentioned the old-fashioned virtue of 
tice of honesty, involves a great deal that is vital in the 
business of nursing the sick. It has been said that the 
average American girl of the twentieth century is ignorant 
of the first principles of obedience. Certain it is that the 
disposition to argue the point, to want to do it some other 
way, to ignore entirely what has been said, to think it 
makes no difference, to ask idiotic questions or to neglect 
an order because it is difficult to carry out, are all prominent 
characteristics of the girl of today who presents herself 
for training. ‘To have a girl who will do exactly what she 
is told, in the manner in which she has been taught, 
without questioning or arguing, or who will promptly come 
and report that she finds difficulty in carrying out an order, 
is to possess a treasure whose value to the institution 
cannot be measured. She imparts a sense of security 
and confidence wherever she is on duty that is in striking 
contrast to the feeling of anxiety, of constant uneasiness, 
produced by some other nurses whom a head nurse never 


MOSPITAL ETHTCS 199 


feels she is sure of unless she is standing guard over them 
to keep them up to the mark. 

In all hospitals will be found nurses who are unattrac- 
tive in manner, nurses who are untactful, nurses who are 
indiscreet, nurses who are, sad to relate, not always truth- 
ful, nurses who are noisy and frivolous, while doubtless 
every one of them possesses some of the qualifications so 
desirable. Out of this imperfect and often unpromising 
material are to come the nurses of the future. The great 
majority come with very crude ideas as to what training 
really means. Most of them have grasped the thought 
that it means they are to be taught to do a great many 
things for sick people and to get through with a certain 
course of study; but that their own personal habits are 
to be interfered with has, perhaps, never occurred to them. 
Few candidates, if any, realize how much their own per- 
sonality, their own manner, is to figure in their success. 
As a matter of fact, there is no line of work in which per- 
sonality counts more. A patient may put up with rough, 
uncouth habits in a physician, and often, foolishly, think 
it a mark of genius or skill, but not so with the nurse. 
“Tt is a rare thing for a patient to ask me where I trained,” 
said a nurse in private practice. “The majority of sick 
people know very little about hospitals or training-schools, 
but they and their friends knew whether they liked me or 
not, and, after all, that is what counts.” She spoke 
truly. It is personality that counts everywhere. A 
pretty face is not a disadvantage, but it does not always 
imply a pleasing personality. What the physician wants 
is a nurse who has learned to obey, who can be trusted 
with the patient, and who will refrain from adverse criti- 
cism of him or his methods. What the patient wants, 


200 HOS PITA LE Taare 


what his friends want, is some one who will take in the 
situation and adapt herself to conditions, who will get 
along without friction, who will upset the plans of the 
household as little as possible, who will have a kind, cheery 
word for everybody, even to Dinah in the kitchen; who 
will see to her own patient’s wants and wait on herself, 
who will not try to organize a miniature hospital and de- 
mand clean sheets every day; who will consider the drain 
on the finances of a family that sickness makes, and will, 
therefore, make as few demands as possible. Itis the nurse 
who has learned to put up with the odd ways of people, 
to humor them when it makes no difference, the nurse 
who has learned to please, who is wanted. 

There is a tendency, too, that needs to be watched 
against, for the nurse to be spoiled by the unstinted praise 
that is sometimes showered on her by friends when she 
has helped a patient successfully through a serious illness. 
The gratitude of patients and friends is one of the com- 
pensations that come to nurses everywhere, and ingrat- 
itude is always to be deplored. At the same time it is 
well to remember that “gush” may mean short-lived 
praise; that the patient who says little may often feel 
deep in his heart a sense of gratitude he cannot express. 
Further, the nurse must learn to do her duty, and to be 
satisfied many times with the approbation of her own 
conscience, to render service to the uncouth and unlovely, 
irrespective of appreciation or material rewards, if she 
is to be a real force in making this world a better place to 
live in and to die in. 

There is another ethical point on which too stringent 
| regulations cannot exist or too strict supervision be made— 
flees is regarding the nurse’s relations with men—the male 


Ine SPY t Af EE Pes 201 


patients, the orderly, the porter, the patient’s friends, 
the physicians, the internes—all men. Because this is a 
delicate subject to approach it is simply ignored in some 
hospitals. While all are ready to admit the importance 
of the question, yet it is the one thing that is not discussed 
fairly and openly by some superintendents with their head 
nurses and pupils. From the very first day of a nurse’s 
career in a hospital she should be given to understand in 
unmistakable language that the thing required is that 
every nurse shall conduct herself so that she will be above 
suspicion inside the hospital and outside. The whole 
world is not desperately wicked, but there is a considerable 
portion of it that is desperately weak. It is just as well 
for superintendents to accept that fact without question. 
To launch a girl who has had little contact with the world 
as it really is on a hospital career, without warning her of 
temptations that will surely come to her,—temptations of 
which she has never before dreamed,—is a crime that, 
in the light of experience, is inexcusable. After a few 
years’ experience with life as it is lived in a hospital nurses 
will be wiser about such things. In their early days 
they need to be guided by the wisdom of others, who have 
been over the road and know where they are likely to 
stumble or “make fools of themselves.” 

It is one thing to theorize about ethics, and handle the 
whole question as an abstract problem, or as we might 
discuss astronomy or any other far-away, shadowy subject. 
It is another matter entirely to handle ethical questions 
fairly and squarely, as such questions relate to every-day 
life and conduct, and to the people we have to deal with 
inside the four walls of any given hospital. Gladstone’s 
prescription for many evils is very necessary—"A. little 


202 HOS PIT A Lie: tee ae 


common sense.” When, after plain warnings and admoni- 
tions, a nurse conducts herself in such a manner that she 
becomes subject for gossip or criticism because of indiscreet 
conduct where men are concerned, the sooner she is gotten 
rid of the better for everybody concerned. It is an in- 
justice to self-respecting nurses, to the hospital, and to 
the profession to retain her and graduate her, however 
efficient she may be. What she is, is more important than 
what she can do. 

The question of penalties for violations of rules is a big 
one, and one on which opinion is greatly divided. ‘Taking 
away a nurse’s cap is sometimes tried, but it does not 
seem wise to thus humiliate a nurse before the patients 
whose respect she must keep. The ranking system in 
some large hospitals, where no private patients are ad- 
mitted, has been successful, but it could not be as success- 
fully applied in smaller hospitals or hospitals with a large 
proportion of private patients. Each nurse is given her 
rank in the order of her arrival, such rank being observed 
in seating in the class-room, dining-room, assignment of 
work, etc. After the first examination the rank is accord- 
ing to results. Failure to come up to a certain standard 
of work is sufficient cause to place a nurse farther down 
the ranks; otherwise she is promoted as vacancies occur. 

Depriving a nurse of her afternoon off for being late 
at breakfast, or late getting in, is advocated by some who 
have tried it. Sending a nurse off duty for lack of neatness 
or for boisterous conduct, and causing her to lose a half- 
day, impresses the lesson on her, and on the whole class, 
as hours of talking would not do. Failure to answer bells 
is one of the things that has to be constantly dealt with. 
For this offense suspension for a week has accomplished 


BOsSPITAL £ CE ECS 203 


what seeemed impossible without it. No one wants 
to suspend nurses, but indifference to the calls of the 
patients is something that cannot be condoned. For 
omissions ing orders some superintendents have 
tried the plan of calling the nurse to the office and requir- 
ing her to confess it to the physician. This has proved 
a more effectual way of dealing with it than letting him 
find it out himself, and perhaps pass it over without 
comment. It is all very well to theorize about “ruling 
by love,’ but in hospitals it has been found practically 
impossible to enforce regulations with some nurses until 
some penalty was attached. In debatable maiters it is a 
pretty good rule to remember that what we would not 
want forty nurses to do we have no right to allow one to do. 

When it comes to methods of maintaining discipline, a 
great diversity of opinion exists. It is undoubtedly true 
that methods that are highly successful in one hospital 
would utterly fail in another, or be impossible of adoption, 
because of the difference in the types of hospitals concerned. 
Also, it is true that the same nurse might require different 
treatment at various stages in her career. Successful 
discipline requires that nurses be dealt with as individuals. 
The probationer who arrived two days after the appointed 
time, or who spent a day in sight-seeing with her friends 
before reporting at the hospital, thinking it made no differ- 
ence whether she started her course today or tomorrow 
or the next day, should be seriously talked to on the sub- 
ject. The opportunity of teaching the necessity of obe- 
dience and punctuality, of showing how her failure to 
report on schedule time might disarrange the working 
of the machinery in various parts of the hospital, should 


204 HOSPITAL (\E 2 ies 


not be neglected; but if a nurse who had spent a year 
in the hospital came in two days late after vacation, she 
should be more severely dealt with. A good rule in some 
hospitals for this breach of trust is to require two days’ 
extension of the training period for each day taken without 
permission. 

One of the hard lessons to teach is the necessity of nurses 
regularly and frequently reading orders so that nothing 
is overlooked. Another point difficult to impress is that 
no order is to be omitted simply because it may be diffi- 
cult to carry out, or that failure of one person to attend 
to her part of the work does not excuse another. So 
frequently a thoughtless nurse will make an attempt at 
carrying out an order, give it up without really accom- 
plishing it, and say nothing aboutit. Ifa medicine ordered 
is not at hand, for instance, some nurses will feel at 
liberty to omit it, without reporting the occurrence at the 
time when it should have been attended to. Let this 
habit of omission become prevalent in a hospital, and 
how can a physician or a superintendent be sure that any 
order will be carried out? Inattention to orders in the 
army or in a railway system is the cause of numerous 
disasters. It is the same in the hospital. Such delin- 
quencies should never be lightly passed over. In some 
hospitals a great point is made of the violation of rules 
regarding the time a nurse must be in the house or have 
her light out, while these weightier matters, that have 
to do directly with the sick, are too often passed over as 
common or unimportant occurrences. In the study of 
literature and rhetoric we found the point of due propor- 
tion was one of the important things emphasized. To 
have a proper sense of due proportion in dealing with 


OS Pil AL, EE Rees 205 


nurses’ offenses and shortcomings is equally important 
to good results. 

The nurse who has been told never to apply a hot-water 
bottle to a patient with the water hotter than 115° F., and 
in direct violation of a known rule fills the bottle with 
water at a temperature of 150° or 200° F., is a dangerous 
element in a hospital. If she burns a patient and the 
offense is lightly passed over, we may expect other nurses 
to become less careful. ‘There are careless nurses; there 
are others whom we dare hardly with justice call “care- 
less,” but we must admit that in some things they are not 
sufficiently careful. The thing we want to do is to pre- 
vent the nurse who is “not sufficiently careful’ from 
getting into the “careless” class. 

At the very outset of a nurse’s career, and at frequent | 
intervals during her training, the fact needs to be impressed | 
on her that it absolutely depends on herself whether | 
she is to become a first-grade, second-grade, or third-grade | 
nurse. That fact she absolutely controls. As a rule, she’ 
is inclined to blame the training-school for many of her 
shortcomings, and while the school has a decided respon- 
sibility regarding its nurses, it still follows that the girl 
herself becomes largely what she determines to be. If she 
is satisfied to do slipshod work; if she is lacking in thorough- 
ness and punctuality and accuracy; if she is satisfied with 
mediocrity in her daily work, then she has no right to 
complain if she never rises above it. 

Her real character is expressed in numberless ways of 
which she will be unconscious unless instructed. Her 
voice, her laugh, her conversation, her walk, her touch, 
her habits of dress, the expression of her face, all tell their 
own story and bear on the question of her fitness or un- 


206 HOSPITAL ET iis 


fitness for the work she has undertaken. While it is often 
a delicate and disagreeable task to call a nurse’s attention 
to her own personal defects, it is certainly no kindness to 
her to disregard them. At the very time when a weakness 
is manifested is usually the best time to call attention to it. 
If frequent admonitions on the subject seem to be unheeded 
and the matter is important, it becomes a point to be re- 
ported to the superintendent, to be dealt with asmay seem 
best for the candidate and the institution. 

One of the first lines on which nurses need to be cautioned 
is regarding discreetness of speech, and this refers not only 
to affairs concerning the patients, but to the nurse’s own 
private affairs. ‘There are nurses who can never be trained 
to hold their tongues. ‘They seem to have inherited a pre- 
disposition to “tell things,” in spite of all that any one can 
do, just as, in the great world outside hospital walls, there 
are men and women foolish enough to even “tell that their 
father was hanged,” when no one particularly cared how 
he met his death. The information was entirely uncalled 
for. Such people do aspire to nurse the sick, and they are 
bound to be a trial to the soul so long as the notion lasts. 
Then, too, there are nurses who come from homes in which 
any restraint of speech is unknown; their attention has 
simply never been called to the need of it. There are 
nurses who are foolish enough to relate their own private 
affairs, or their love affairs, to the nurse acquaintance of a 
day, or to the patient who is to them a stranger. ‘Thus 
the question of tongues constitutes one of the problems 

of the training-school. Head nurses can do much by ex- 
jample, as well as by precept, in helping nurses to form 
| those habits of reticence that will go far toward commend- 
jing them to the confidence of physicians and people in 


HOS Pol T AE. Re Ee ices 207 


general. ‘To be able to say that a nurse is a “safe” woman 
to admit into one’s confidence is no uncertain commenda- 
tion. No point needs more frequent emphasis than this. 
To send out nurses who know how to keep silent regarding 
their own or their patients’ affairs without conscious effort, 
because of habits firmly fixed during the training period, 
isno small achievement. ‘To train them to be ladies under 
all circumstances, to avoid practical jokes, undignified 
conduct, slang, and gossip is as important, surely, as a great 
deal of the technical knowledge that now seems to be de- 
manded in a nursing course. 

If all nurses could be given a thorough drilling in how to 
carry themselves and how to acquire a graceful walk it 
would be a distinct advantage to many nurses who have 
unconsciously allowed themselves to become round-shoul- 
dered or awkward and ungraceful in their general move- 
ments. No one who has seen the difference in the bearing 
and carriage and walk of the volunteer for the army before 
he enlisted, and the same man after he has had a few months 
of military drill, who has noted the erect carriage, the firm, 
even tread, can question the value of gymnastic drill and 
exercises in the training of nurses. Even without the for- 
mal drill much can be accomplished, given willing, teach- 
able pupil nurses and tactful head nurses who will call 
attention to personal defects, and remind, and remind, and 
remind, until reminders are no longer needed. 

“Study to be quiet,” is a text that ought to be writ large 
and posted prominently in all our hospitals and training- 
schools. Have we really regarded it as a subject for study ? 
Have we not, in hospitals, expected nurses to acquire habits 
of quietness by accident or instinct? Is this not one reason 
why we hear such frequent complaints from patients and 


208 HOSPITAL ET Eeee 


their friends about the noise in hospitals? It is true that 
physicians are very bad examples for nurses in this respect, 
that some internes are simply irrepressible so far as noise 
is concerned, but are head nurses as careful as they should 
be to teach habits of quietness, to demand it, and use all 
possible means to secure it? Unless nurses are trained to 
notice noise—preventable noise; unless their attention is 
called to the thousand and one points to be guarded against 
while engaged in active duty,—the banging of doors, the 
rattling of basins, the creaking of hinges, the noisy handling 
of chart-files, and, most inexcusable of all, their own voices, 
their own often unnecessary chatter, which keeps up a con- 
tinual disturbance among sick folks,—they will certainly 
develop noisy habits that are bad for the hospital, bad for 
the individual nurse, bad for future patients, bad for every- 
body concerned. Have we not been far more attentive 
to such points as whether the bed-spread was on exactly 
as prescribed, whether the window-shades were all at a 
uniform height, whether the wash-cloths were in their 
exact places, than whether our nurses were needlessly tor- 
menting the patients with their chatter and noise ? 

The habit of expressing appreciation of work well done, 
and of measuring and noting general improvement, is 
another point worthy of cultivation in the head nurse. 
There are comparatively few individuals who do not relish 
and long for a word of commendation, comparatively few 
who will keep up sustained effort to improve, if they think 
nobody notices or cares. 

One other point may be mentioned on which head nurses 
need to be decidedly on the alert—that of allowing proba- 
tioners or pupil nurses to criticize the management or 
methods in their presence. It is no part of a pupil nurse’s 


mos PUT AL Eo rares 209 


duty to plan or produce reforms in an institution. If they 
are wise they will soon recognize that to readjust them- 
selves, to do faithfully, quietly, and efficiently the duties 
assigned to them, is the best way to improve a situation. 
If they have theories which they are burning to experiment 
with, and they prove successful in their own little sphere, 
the chances are that the opportunity to test their advanced 
theories will come to them sooner or later. The world is 
not slow to recognize ability, and it is badly in need of 
people who have in them the qualifications for leadership 
in any line. 

When a nurse shows the disposition continuously to 
grumble and criticize; when her attention has been seri- 
ously directed to the fault with no sign of improvement, 
the quicker that nurse is gotten out of the hospital the better. 
However clever and capable a nurse may be, no institution 
can afford to harbor a girl who has a tendency to keep stir- 
ring up trouble, to keep seething, an element of discord 
that will poison the atmosphere and make her associates 
discontented and unhappy. There are some dispositions 
that can never accept sweetly the regulations of community 
life or get along comfortably with a lot of different kinds of 
people. There are incompatibilities that will always prove 
troublesome in institutional life, that have to be endured, 
but the active stirrer-up of trouble who feels called on to 
reform the place is a type that no superintendent can afford 
to keep if she values her own peace of mind or harmony in 
the school. Half the troubles that are experienced with 
discipline in training-schools would be avoided if pains 
were taken to ferret out the leading spirits in creating 
trouble and promptly get rid of them. No head nurse 


who really has the interests of a hospital or training-school 
14 


210 HOSPITAL E THRWGs 


at heart can afford to shield or to keep silent regarding this 
class of individuals. 

How to bring out the best that is in her nurses; how to 
strengthen their weak points, is one of the problems at 
which the conscientious, capable head nurse is always work- 
ing. Todo the best with them she must understand them, 
must try to see things from their standpoint as well as her 
own. She must be able to look beneath the minor fault 
or error, and appreciate the motive that prompts an act. 
She must aim at eliminating root defects, which, when 
righted, will generally correct minor failings. In the daily 
dealings with nurses and probationers she will meet some 
who will need to be spoken to in the most emphatic manner 
possible—fairly thundered at—if any lasting impression is 
to be made. She will have to deal with others, in whom 
the least suspicion of severity will break them up and unfit 
them for work. Some nurses, like some children, need 
to be held in, as it were, with bit and bridle; others can be 
managed by a look or a suggestion. Both kinds may de- 
velop into good nurses, but they need entirely different man- 
agement in the developing process. 'To be able to rebuke 
without arousing antagonism is no mean attainment. To 
see the possibilities that are embodied in unpromising, 
blundering material; to detect the latent powers and help 
in their development, has its own reflex action, both broad- 
ening and elevating. Fortunate is the head who realizes 
the greatness of her opportunity, or who has inspired such 
confidence in her subordinates that they will, even while 
smarting under a reproof, realize that she had their highest 
good in view. ‘The time will come in later years when 
they will appreciate at its true value their training and 
teaching, when they will regard as a blessing the discipline 
of their training-school. 


CHAPTER XxI 


Ward Housekeeping and General 
Management 


In the general management of a large ward or a section 
of a hospital a head nurse will find ample opportunity for 
the exercise of both technical and executive ability. The 
nurse whose professional education has been built on the 
solid foundation of a thorough practical knowledge of 
housekeeping is, as a rule, better fitted to fill such a posi- 
tion than the woman without practical domestic exper- 
ience. 

It is not unnatural that a feeling of bewilderment should 
take possession of even the most self-possessed nurse who 
finds herself thrust into such a position in a hospital to which 
she is a stranger, but a couple of days in the place will make 
a decided change in this respect, and a couple of weeks 
ought to see the clouds disappearing entirely from her hori- 
zon. She should begin to see the situation clearly. From 
the very beginning the head nurse will do well, even though 
it may not be a rule in that particular hospital, to be 
always at her post when the nursing staff changes. Only 
thus can she be sure that the orders will receive prompt 
attention; that appliances used by the staff going off duty 
are all in their proper places; that the entire department 
of which she is in charge is in order; that the work for the 
next relay starts out as it should. The very fact that she 
is there and notices such details will have a good effect in 


keeping up standards of work. 
ya 


212 WARD HOUSEKEEPING 


To make a careful observation of the standing orders 
will perhaps be her first duty—the orders and rules that 
apply to her, those that apply to the nurses she will direct. 
After that will come the looking over the records and the - 
details of the ward in general. It is well for her to under- 
stand that there is no detail that may pertain to the com- 
fort of the patients or the general well-being of the ward 
for which it is not her business to be responsible—nothing 
so small that she can afford to be careless about it. 

The periodic supervision of the condition of the beds 
is one matter that head nurses are inclined to overlook. 
It may as well be taken for granted that there will always 
be nurses who, regardless of how thoroughly they have 
been taught, will be careless about their bed-making if 
they are allowed to be. In beds on which the spread is 
straight and neat, beds which to the superficial observer 
appear to be up to the mark, it will often be found that 
three or four days after an operation the operating-room 
stockings are still in a heap at the foot of the bed, and the 
towel that was pinned in place to protect the sheet while 
the patient was recovering from the anesthetic is still 
there under the pillows, showing that the bed has not been 
thoroughly made in that time. At other times crumbs 
will be found, increasing the discomfort of a patient 
already worn with pain and restlessness. 

Another matter that demands careful supervision is 
the trays. For that reason it is highly important that a 
head nurse should always be in her ward when regular 
meals are served, to note the appetite of the patients, 
to be-sure that helpless patients or those confined to a 
recumbent position are either fed or have the food given 
to them, so that they can take it with the greatest ease 


Wie D HO US EK EE PoNG 213 


possible for them. On a visit to a typhoid-fever patient 
in a private room recently he was found with a good slice 
of broiled steak (which he was allowed to chew) cooling 
before him. He was absolutely confined to the recum- 
bent position, and the thoughtless nurse had simply 
carried the piece of steak as it came from the kitchen, set 
it on the table, and walked out without cutting it or in 
any way attempting to fix it so he could eat it. There 
are a great many thoughtless pupil nurses in the training- 
schools of today, nurses who might be expected to display 
more real ability in managing such things than they do. 
It is not enough that they are taught how and when a thing 
should be done, but some one must be on hand to see that 
it is done. 

How is the head nurse to do this, if physicians persist 
in coming at mealtime to make their rounds? In some 
of the leading hospitals in New York there is a standing 
rule posted in conspicuous places to the effect that no 
physician who comes to do dressings or make rounds at 
mealtimes (the regular hours) is entitled to the assistance 
of a nurse. It is a wise measure that should be observed 
in every hospital. Once the doctors understand that 
such a rule is there and will be enforced, they will adjust 
their hours to more convenient times. 

The preparation of the diet-sheet is another duty that 
falls to the head nurse. Usually these are prepared at 
night, sent to the superintendent to be signed, and when 
the sheets from all the departments are collected, the 
quantities are aggregated and sent to the housekeeper. 
There are some few of the head nurse’s duties that may 
safely be left to pupil nurses, but this is not one of them. 
Not long since a superintendent found that a head nurse 


214 WARD HOUSEK ERPs 


was actually requiring a probationer, as a routine prac- 
tice, to make out the diet-sheets and order the supplies 
for the ward, while she attended to what she considered 
more important duties. . 

One of the most common errors to which head nurses 
are liable is the doing of the actual duties that ought to be 
performed by the pupils, thus allowing them to depend 
on her to supplement their efforts, instead of supervising 
and teaching. ‘This is one of the chief reasons for failure 
with some head nurses. Instead of using their brains 
to plan and systematize the work and teach, they dabble 
in perhaps every duty the nurses have to do. If the nurse 
did not get around in time to dust the ward, they dusted 
it; they cleaned cupboards; made beds; wrote up records; 
did whatever they saw to be done, and, very soon, the 
nurses learned that certain things might be left every day 
and the head nurse would attend to them. In many 
cases it would certainly be easier to do the things than to 
take pains to instruct a novice in the art, or to plan a whole 
morning’s work in detail and show a nurse how to go 
about her work systematically and get through, but that. 
is not training nurses. 

In the matter of bed-linen a good deal of care needs to 
be exercised. There has been, of late years, an outery 
from private homes about the extravagance of nurses 
regarding linen, a fault for which our hospitals are mainly 
responsible. There is a happy medium to be aimed at 
in this matter. ‘Too great economy is never commendable, 
neither is extravagance. The laundry work in a hospital 
is always a heavy item. An investigation recently as to 
the reason for the constant cry of shortage of linen in a 
certain hospital showed that some nurses changed beds 


WARD HOUSEKEEPING 215 


every time they gave a patient a bath, whether the linen 
was soiled or not. Clean folded sheets were used as pads 
under bedpans, and for various other irregular purposes, 
while the same kind of extravagance was discovered in 
the matter of towels. All the time the head nurse was 
there, seeing about treatments, personally directing the 
nurses in some matters, and entirely ignoring the question 
of linen, as though it was something for which she had no 
responsibility. 

In the matter of household work ‘and cleaning a head 
nurse will save herself much needless anxiety by making 
out a schedule covering the entire department of which 
she has charge, and stating definitely the work to be done 
each day and the hour at which it is expected to be com- 
pleted. Only thus can she hope to keep her section in 
good condition. If ward maids or nurses find that it 
makes no difference whether they sweep or dust before 
noon or after, embarrassments will constantly occur. 
When this schedule has not been made out, it has happened 
that the ward has been undergoing a sweeping while the 
patients’ dinners were being served—an actual fact, in 
this age of supposed sanitary intelligence! It is well 
also to remember that once duties have been assigned to 
Jane, they are not to be performed by Maria or Peter, 
even if Maria and Peter are good-natured enough to offer 
to do them. Ten chances to one Maria and Peter are 
themselves neglecting something on their own schedule 
while they are posing as kind-hearted individuals where 
they do not belong. When a heavy day comes, the effect 
of good or bad management in this respect will be most 
in evidence. ‘There are occasions when perhaps she can 
afford to excuse indifferent work, but no probationer or 


27146 WARD HOUSEKEEPING 


pupil nurse should get the impression that a head nurse 
is “easygoing” and that slackness will be tolerated. 

The necessity of having a place for everything, and 
insisting that it be kept there when not in use, is another 
matter that requires frequent emphasis. Valuable time 
is wasted, tempers are ruffled, harsh words are spoken, 
often, because this rule is not adhered to in some hospitals. 
A night nurse, for instance, uses a hypodermic syringe or 
a roll of adhesive plaster, drops it somewhere, and for- 
gets about it. The day nurse comes on, thinks she 
can go immediately and put her hand on it, and has to 
chase hither and thither searching for the missing article. 
Hypodermic needles are left without wires, and next 
time they are needed a new needle has to be sent for. 
When these things occur the fault lies very largely 
with the head nurses. ‘They do not hold nurses strictly 
to account for these things or follow up till they find the 
delinquent. 

The daily inspection of refrigerators, ward-lockers, 
table drawers, takes but a few minutes and goes a long 
way in keeping those out-of-sight corners in proper con- 
dition. In the matter of plumbing, too great care cannot © 
be exercised to see that dressings or other insoluble mat- 
ter are not allowed to obstruct the flow of water. Like- 
wise the need of repairs should be promptly reported. 
When a screen is found broken, or a rocking-chair that 
needed but a screw to put it in order, a door that will not 
open or close properly, and a general run-down condition 
prevails, it is pretty plain evidence that the head nurse 
of that department is in the wrong place. 

A point that sadly needs calling attention to is in regard 
to the use of screens in wards. It would seem, from 


WARD HOUSEKEEPING 217 


observation, that this laxity is more likely to be found 
in the large hospitals with large wards than in the smaller 
hospitals. Frequently the authorities of the hospital 
are to blame, in that they have not supplied easily movable 
screens, or enough of any kind, but it may safely be in- 
ferred that, if there was an urgent demand for more 
screens, they would be provided. Many nurses are apt 
to be careless of this matter, and some will think nothing 
of giving a bath or exposing a patient for catheterization 
or a perineal dressing in a ward without a screen. Even 
in walking down the corridors of some hospitals a visitor 
will see ample evidence that laxity of this kind is far too 
common. It is bad for the nurse herself to allow her to 
be so careless, and it is certainly not conducive to the 
comfort of the average patient to be thus exposed. 

The abuse of hospital supplies and appliances is one 
of the very frequent complaints heard. Wilful extrava- 
gance is not unusual. So many nurses feel that because 
the property belongs to a corporation it can make little 
difference to any one whether they are careless or not. 
A saving of five cents a day for each patient—five cents 
only—on the total supplies of food, drugs, surgical 
supplies, appliances, linen, etc., would go far toward 
saving a hospital from having each year to report a deficit. 
This is another point on which much depends on the 
head nurse. Eternal vigilance, with careful accounting 
for supplies, is the only way by which those addicted to 
such carelessness can be made to feel their responsibility 
for the proper use of the supplies provided. 

Every now and then announcement is made of the 
poisoning of a patient in a hospital by a wrong dose of 
medicine. No head nurse who appreciates her responsi- 


————————— oo ——————————_[_— 
218 WARD HOUSEKEEPING 


bility will ever allow herself to be guilty of carelessness 
where drugs are concerned. Neither will she tolerate 
carelessness in the nurses whom she directs. There are 
a few lessons that need to be repeated seventy times seven 
or oftener in a nurse’s course. One of these lessons is 
regarding the precautions to be used in the handling of 
drugs. ‘Teach them first that there is anelement of danger 
in every drug; teach them never to give or use a drug of 
any kind that is not labeled; never to give a drug in the 
dark; never to omit reading the label carefully and meas- 
uring the dose accurately; never to use a pill or capsule 
that has escaped accidentally from its container; never 
to give a medicine they have a shadow of a doubt about; 
teach first, last, and all the time the necessity of being 
careful in reading the label; that it is not enough to glance 
at a bottle and see the word “opium,” for instance, with- 
out taking time to notice whether it was the tincture or the 
camphorated preparation. Teach that they must not 
hastily jump at conclusions regarding doses—for example, 
must not rush off and give two one-thirtieth grain tablets 
of strychnin because one-sixtieth is ordered—sixtieth grain 
tablets are not at hand, and they happen to know that 
twice thirty is sixty. ‘Teach these few principles thor- 
oughly, drill the nurses on them frequently, keep the most 
strongly poisonous drugs separate from the others, write 
orders clearly and distinctly, and such accidents will be 
few and far between. ; 
One other detail on which head nurses are apt to fail 
is in the arranging of ‘off-duty hours” for their nurses. 
On rare occasions, when the work is especially heavy, 
or in time of emergency, it may be necessary to deprive 
pupil nurses of rest time that is rightfully theirs, but these 
occasions should be exceptional. No head nurse should 


Wik D HOWS BE KOE © PiNG 219 


feel it her privilege to retain nurses over the regular hours 
on duty for extra work, or to allow them to miss their 
time off, without reporting to the superintendent why it 
was necessary. The custom of requiring head nurses 
to report each Saturday night how much -“ off-duty time” 
each of their nurses had had during the week would 
help considerably in securing for pupil nurses the time 
for study and recreation that justice to them demands. 
In many cases where nurses are habitually on overtime 
it may be traced to lack of system or bad management, 
rather than the unusual pressure of work. If a head nurse 
cannot manage the work so as to give, unless in excep- 
tional conditions, her nurses the time off duty they are 
supposed to have, the matter is one to be reported to the 
superintendent, and possibly to the board, for consideration. 

A point which has caused embarrassment in many 
hospitals has been the neglect on the part of the head 
nurse to notify the superintendent when she herself 
was leaving the hospital for a few hours or an afternoon 
off duty. ‘This, common courtesy and justice to the work 
demand. No head nurse who is really fitted to direct 
others will be guilty of this failing, which is more than a 
breach of courtesy—it is a breach of trust. She requires 
her nurses to report to her at such times, and should be 
just as careful to observe the point herself. 

These are but'a few of the responsibilities that devolve 
on the head nurse. While a certain amount of individual 
choice is permissible in the management of the daily rou- 
tine, she should remember her relation to the whole insti- 
tution, and establish no precedents that would create em- 
barrassment if allowed in all departments; she should be 
extremely careful to observe general regulations that are 
made for head nurses or for the institution as a whole. 


220 


WARD HOUSEK EER Pais 


MONTHLY REPORT OF HEAD NURSE 
NURSES’ MONTHLY GRADES 


Nurse 


Maximum number attainable for each point, 3. 


Ea eee Dab 2 in 2:3) sto eee eae 
Per- 

Ae Quiet- | Punc- | Neat- ame ER 

ness | tuality| ness Pa Ae 

Work pear-| ment 
ance 

wideed| sees.et | ee 2e be eee | 

ula | eee 

Head Nurse. 


WEEKLY RECORD OF RECREATION 
AND EXTRA DUTY HOURS 


Week Ending— 


Sun. 


Tuour. |Frmay} Sar. | Torar 
NAMES 
R. | Ex.| R. | Ex.| R. | Ex.| R. | Ex.| R.| Ex.| R. | Ex.| R. | Ex ;R. Ex. 


Head Nurse. 


221 


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WARD HOUSEKEEPING 223 


DAILY DIET LIST 


FLOOR 


WARD 


CLASS OF DIET 


No. of 
Patients 


—PRIVATE 


REMARKS 


General Diet. 


EXTRAS— 


Date 


APPROVED. 


Head Nurse. 


Supt. 


CHAPTER XxII 


Orders and Reports 


To have the orders written so clearly and plainly that 
they are easily understood is the first step toward having 
them carried out. This is another of the important 
duties of the head nurse. The orders actually given by 
the physician constitute but a small part of the treatment 
actually required. In most hospitals there are “standing 
orders’’—general instructions to be observed in regard 
to all patients unless exceptions are definitely made for 
good reason. Years of experience with nurses—good, 
bad, and indifferent—have taught at least one superin- 
tendent that if good nursing is expected, the standing 
orders cannot be too full, too definite or explicit, or posted 
too conspicuously. One would naturally expect any 
nurse to know enough, for instance, to comb a female 
patient’s hair every day without being told. It is only 
after repeated disappointments because of taking things 
for granted that superintendents have learned to include 
such commonplace duties in the standing orders. It is 
not a good plan to depend on standing orders being 
written in the front pages of the order book. ‘There is 
always the danger that they will not be carried over to 
the new book, and some part of the house will be without 
standing orders. Neither is it well simply to post a copy 
on the wall, to be removed by the “‘ Pagan housecleaners,” 


and possibly be carried out with other papers. Have the 
224 


ORDERS AND REPORTS 225 


standing orders printed or typewritten, framed under 
glass, and posted in the bath-room, diet-kitchen, over the 
writing-table, or in some other place where the nurses 
cannot fail to see them frequently. 

When one sees the lack of system of writing orders that 
prevails in some hospitals the wonder is that any orders 
are carried out promptly and properly. Such carelessness, 
if it were to take place on a railway system, would cause 
the public to raise its hands in horror and appeal to the 
government to interfere. It may seem like laying a great 
burden on head nurses to say that the daily orders for each 
patient should be written each day, but it is the only safe 
tule to follow regarding hospital orders where acute cases 
are being handled. If the ward is devoted to chronic 
cases, or ambulant cases, or convalescents, perhaps such 
tulings might be relaxed; and yet, we all admit that the 
period of convalescence is fraught with many dangers; 
but, with the active service that is now the rule in general 
hospitals where life and death are always in the balance, 
too great care and supervision over orders cannot be 
exercised. The method used varies greatly. In some 
hospitals an order-sheet is attached to each chart. In 
others the orders are collected from the separate order- 
sheets and are arranged with the standing orders for each 
patient that are to be specially observed that day, and 
transcribed in a book. In others a separate medicine 
list is kept. 

After a trial of several different methods the system of 
having a record-sheet kept for every patient from the time 
he enters the hospital, with a space at the bottom of each 
sheet for the physician’s orders, has been found by far the 


the most satisfactory. Separate order-sheets for the 
15 


226 ORDERS AND REPORGS 


physicians are very likely to become detached and to 
accumulate and make the chart cumbersome to handle. 
The pupil nurse is responsible for executing the orders 
written in the order-book by the head nurse. The head 
nurse is responsible for taking down the physician’s 
orders if he will not write them himself on the space 
for that purpose at the bottom of each sheet, and for 
transcribing them in the general order-book. While this 
latter method may take more time, it is the surest and best 
method, especially in dealing with probationers or inex- 
perienced nurses. Instead of having to handle half a 
dozen or a dozen chart files to see what her duties are, 
the pupil nurse finds her orders grouped together in one 
book and can check off each order as it has been attended 
to. Thus John Smith may need to have his temperature 
taken every two or three hours, while John Jones, in the 
next bed, requires it only morning and evening. John 
Smith may have to be bathed every day or every few hours, 
John Jones but twice a week. When the standing orders 
say that each patient must have a bath twice a week, it 
might be expected that John Jones would get his bath 
without further orders, but it has been found that Satur- 
day has come without John Jones having had his first bath 
for the week, when his second one should have been due. 
Therefore it behooves the head nurse who wants good, 
prompt nursing to state {n the orders for the day that 
John Jones must get his bath this day. A specimen 
order might read as follows: 

Joun Jones: T. P. R. q. 3h.: 8-11-2-5. 

Bath this A.M. Fluid diet: milk, 3 ounces, with lime-water, 1 ounce, 

alternating with chicken-broth, 3 ounces q. 2h.: 6-8—10—12-2-4. 


S.S. enema A.M.; Strych., gr. 75, hypo., 12 and 6. Measure urine. 
Prepare for clinic at 2 P. M. 


ORDERS AND REPORTS 227 


With orders written thus for each patient there is no 
excuse for omissions, no excuse for a nurse who says she 
did not know she was to do this or that today. It is 
never a good plan to write the orders for some patients, 
and say regarding others, for instance, “see page 4 for 
Black’s orders.” Let the orders for each patient be 
grouped together for the day and then hold the nurses 
accountable. 

In addition to writing orders distinctly and definitely, 
it is well for the head nurse to call attention to any change 
in dosage. ‘This ought not to be necessary. If every 
nurse reads her orders carefully, it would not be neces- 
sary. But there will always be nurses who need special 
admonition along this line. For instance, the dose of 
strychnin might be ordered decreased or increased. If 
the nurse’s attention is not called to the change, she may 
glance at the word strychnin, overlook the dose, and con- 
tinue the first order. ‘These things do happen, and the 
thing to do is to make it as difficult as possible for a 
nurse to make a mistake, and as easy as possible for her 
to do the thing required of her. If we want exactness in 
nursing, we must use every possible means to secure it. 

In the matter of records there is still much to be desired 
in a great many hospitals. If the bedside records kept 
by some nurses were to be shown as evidence of the 
thorough work done by the hospital, they would make a 
forlorn, discreditable exhibition. Thoroughness in this 
respect only comes as a result of careful training and 
supervision. ‘To know how to state clearly, concisely, 
and colorlessly the exact facts about a patient is no insigni- 
ficant accomplishment. It means that careful teaching 
in how to observe and record symptoms and facts has 


228 ORDERS AND REPORTS 


been given and practised, and the teaching can begin 
with the first day of probation. In this as in other matters 
it is never a good rule to take anything for granted. A 
probationer who has been shown how to give a laxative 
enema has doubtless been led to believe that a good result 
was obtained with a free evacuation of the bowels. She 
was told, perhaps, to note on her records ‘‘good result.” 
Such a girl might be excused if, after giving a pint of salt 
solution which was intended to be retained and absorbed, 
she recorded a “good result” when the patient immedi- 
ately expelled it. She might be excused, but her instructor 
should not be excused for not having given clearer teach- 
ing regarding it. Thus these practical points might be 
mentioned by the dozen. 

There are certain facts that should be made a matter of 
record on every sheet. First, the patient’s name, thus: 
“Mrs. Mary Smith,” not her husband’s name, Mrs. Peter 
Smith. The physician’s name, the date, and the name of 
the nurse should be filled in the blank space provided, not 
only on the first sheet, but on every sheet. ‘The amount of 
sleep should be estimated in hours. Such statements as 
“slept pretty well” or “had a good night” are too vague 
and general to be worth anything. If a patient is on fluid 
diet, the exact amount and the food that has been taken 
should be noted. In other cases the class of diet, as 
semisolid, light, or general diet, will usually be suffi- 
cient, unless in case of gastric or intestinal disturbance, 
when it will be best to state the articles of food given. 

One thing that usually requires great emphasis, careful 
watching, and strict dealing is the time when records 
are made. Nurses who are otherwise conscientious will 
often allow hours or half-days to go by without making 


Gey ERS AND REP OR Fs 229 


a single entry. Then they will guess at hours, trust their 
memories for temperatures, pulses, and respirations of 
half a dozen patients, put down a haphazard estimate of 
doses given, and the time, and call that sheet “a clinical 
record.” Asa statement of facts, it is not worth the paper 
on which it is written. Records that look neat, on which 
the penmanship is beautiful, the statements made in 
correct style, are often, in fact, nothing more than records 
of a nurse’s unreliability. A case comes to mind of a 
graduate nurse on a special case in a hospital. The case 
was intussusception, about seven inches of the bowel 
having been removed. The little fellow was crying 
piteously from hunger one afternoon when the superin- 
tendent went in. The nurse had gone out for a walk. 
Thinking it might be time to give him some nourishment, 
the superintendent picked up the record to see when the 
last had been given. It was then about 5 p.m. Not an 
entry had been made since the physician had made his 
morning visit at 9.30. The superintendent took the pains 
to notice the record the next morning, and everything 
was set out in beautiful shape. Every hour, even while 
the nurse had been away, she had given him some treat- 
ment, according to her record. This is the kind of thing 
that superintendents and head nurses have to watch for 
and fight continuously—not with all nurses, but with 
a few nurses. 

There is only one thing worse than neglecting to make 
records at the proper time when the duty is performed, 
and that is, recording before the thing occurs. ‘This is 
done, unfortunately, by some nurses, probably in every 
hospital. Nurses who have given a good report of them- 
selves in other ways have fallen under that subtle form of 


230 ORDERS AND REPORTS 


temptation. They have been found recording as having 
given, for instance, 8 o’clock treatments at half-past six. 
On inquiry as to how it came that a record was made of 
nourishment given to a patient at 8 o’clock when it was 
still only half-past six, the nurse said she “happened to 
have a little spare time and she thought she would just 
fix up her records.”’ She said that, of course, she would 
do everything she had written down. Her intentions may 
have been good, though her methods were bad, but can 
any hospital afford to bother providing paper and pens 
and ink to record what a nurse intends to do? Why 
volumes might be written every week about nurses’ in- 
tentions, but what would they amount to? What the 
hospital wants, and the physician wants, are facts regard- 
ing duties actually done, things or conditions actually 
observed. Nothing else has any value for them as records, 
and yet this thing will continue to be done by some few 
nurses in every hospital unless a strict supervision over 
all nurses and all records is the rule, and unless there is 
a severe penalty attached to such an offense. To the self- 
respecting citizen the laws against stealing are no burden. 
To the self-respecting nurse the laws against such prac- 
tices will be no burden and they do help to deter weaker 
characters from giving way to such temptation; they do 
help in maintaining high standards. All good laws have 
an educational effect. ‘There is only one word needed 
to characterize such actions, the little word, /-2-e, unquali- 
fied. If a record says anything to a physician, it says of 
a certain thing duly entered at a certain hour, “I have 
given that treatment,” when the facts were the nurse 
had recorded her own intentions as facts. The value 
of any record depends, after all, pretty largely on the 


GEDE R'S°*AN DO REPORT'S 231 


conscience of the nurse who makes it. For this reason 
a poor penman and a poor speller, with good natural 
ability and a good healthy active conscience, is worth 
infinitely more in the sick-room than the cleverest college 
graduate who keeps her conscience wrapped up or never 
uses it except when some one else is around. 

A weak point in many records is in the neglect to note 
important facts. This seems an absurd statement, but 
it is true. There have been stored away in the archives 
of some hospitals records of midwifery cases in which the 
birth of the child was never mentioned. The circum- 
stantial evidence was pretty strong that there had been a 
baby connected with the case. Here and there on the 
record it was stated that the “baby nursed,” or had its 
temperature taken, or, perhaps, had a bath, but when that 
baby arrived on the scene of action, whether it was normal 
or defective in any way, whether it was a male or female, 
whether it was white or black, whether it weighed two 
pounds or ten, its nurse entirely neglected to record. ‘The 
same kind of thing is true of many operative cases. 
Nothing is on the records to show that there really was 
an operation. 

In recording the course of surgical cases or midwifery 
cases it is a good plan to note the days as they pass, count- 
ing from the principal event thus—Monday, January 
24th—fifth day. It is quickly done, and it saves a 
doctor’s time in counting back, as he usually does, in con- 
sidering the removal of stitches, dressings, sitting up, ete. 
The date and the hour of an operation should always be 
noted on the nurse’s records. The operating-room records 
should contain the report of the operation, what was done, 
what anesthetic, sutures, and ligatures were used, 


232 ORDERS AND, REPO We 


together with a general statement of the findings at the 
time, but that does not excuse a nurse from stating on 
her report of the case at least the time the patient went to 
the operating-room and returned. 

Another point that should always be noted is that a 
wound was dressed. It is much more important many 
times to note that fact, for instance, than that a tempera- 
ture in which there was no change from day to day had 
been taken. Yet the one is done and the other left 
undone, as routine practice in some hospitals. There 
is urgent need that some hospitals wake up and take more 
notice of records and get away from the bondage of habits. 
A little study of the question, and a little more careful 
instruction to nurses as to important and non-essential 
points, would surely be worth while. 

Another point that helps in various ways is to require 
nurses to state on the records when a drug is discontinued. 
The length of a chill, the character of the breathing, if 
at all unusual, the appearance of any abnormal discharge 
from a cavity or eruption on any part, are points that 
require a little special emphasis with many nurses. For 
instance, in the case of a colored boy brought into the 
hospital with frozen feet, the doctor watched the toes 
carefully, instructing the nurses to observe closely certain 
symptoms. His medicine was regularly given, the gen- 
eral care was good, but of five nurses and an interne, 
besides the physician in charge, who had been on duty 
with that colored boy, not one of them reported a sus- 
picious-looking eruption that was on his hands, face, and 
other parts of the body, until a bright, wide-awake young 
man nurse was put on the ward, and the first day reported 
these suspicious findings to the superintendent, It was 


Coe DoE RS AND: RoE P O'R TS 233 


one of the worst venereal cases that had ever been admitted 
to the ward, and yet no precautions had been taken to 
prevent infection till nearly a week had passed. Nurses 
are prone to fall into ruts, to get into the habit of mechani- 
cally recording what they themselves do, while they often 
neglect to note important facts which they see or ought 
to see. 

It is well also that the head nurse should not fail to 
correct a tendency, sometimes manifested, unintention- 
ally, to attempt a diagnosis and record it. For example, 
a nurse will thoughtlessly state that a patient is suffering 
from neuralgia or is hysteric, when, as a matter of fact, 
the ablest physician will sometimes find difficulty in decid- 
ing whether he has to deal with hysteria or neuralgia. 

The ability to decide between significant and unim- 
portant symptoms comes only with careful instruction, 
experience, and practice, extended over a long time, but 
it is safer to teach nurses to lean to the habit of keeping 
full records, rather than that, for the sake of brevity, 
they should neglect to note facts that have an important 
bearing on the case. 


CHAPTER XXII 


The Night Supervisor 


The chief night nurse occupies a position of peculiar 
responsibility. She sees very little of the physicians, 
rarely receives orders from them, yet is held responsible 
for the execution of those orders. It is hers to discern 
the importance or significance of certain symptoms, her 
business to decide as to the wisdom of calling up the 
interne, or, it may be, the physician in charge of the case, 
or, In some circumstances, to summon the patient’s 
friends in the event of serious change. It falls to her lot 
to meet emergencies of all kinds, to usher in the accident 
case or the maternity patient, and make hasty prepara- 
tions, to meet, resourcefully and promptly, the thousand 
and one situations that arise at night in a hospital devoted 
to the care of patients suffering from acute diseases and 
accidents. She, as a rule, writes no orders for her night 
staff, yet must see that the orders written are properly 
and punctually carried out. 

Her work is, to a large extent, dependent on the day 
head nurses. They can do much to remove difficulties 
for her or to create them. While it is readily admitted 
that for the good of all concerned the most cordial rela- 
tions should exist between the day and night supervisors, 
as a matter of fact, the attitude assumed by both is very 
often unnecessarily critical and harsh. A little whole- 


some criticism is good for both parties. If the day nurses 
234 


Nee Mr SURE R VES OR 235 


went off duty leaving utensils not cleaned up, the head 
nurse in charge of the delinquents ought to thank the 
night supervisor for calling attention to the neglect. It 
is the only way to maintain standards of cleanliness 
and order. But, is she thankful? Sometimes, perhaps, 
but often she resents it, and the same is true on the other 
side. 

While in regard to rank the day and night supervisors 
are equal, yet in the matter of housekeeping and general 
ward management more responsibility rests on the head 
nurse in charge during the day. She, as a rule, ushers 
in the new patients and receives orders and explanations. 
It is not only a kindness, but a duty, to give to the night 
supervisor as full a report as possible, especially con- 
cerning those patients who are most seriously ill. What 
instructions have been left in case alarming symptoms 
develop? Is a certain patient who has been a special 
cause of anxiety better or worse? Has any special change 
occurred since the doctor saw him in the morning? Has 
the doctor left any special instructions about calling him? 
These are questions where individual judgment comes 
largely into play—questions in which the utmost harmony 
between the day and night staff is necessary. There are 
some head nurses who seem to go about with a chip on 
their shoulder, ready to argue over the slightest matter, 
and especially to pick a quarrel with the head nurse who 
alternates with them. Such nurses are out of place any- 
where in an institution, and particularly as head of a 
department. 

The night supervisor should be slow to criticize the 
day head nurse regarding management, and should upset 
her arrangements as little as possible. When she finds 


236 NIGHT SUPER Visto 


it necessary to do so, common courtesy would suggest 
that she use the first opportunity of making explanations. 

The comparative freedom from interruption from out- 
side sources makes it possible for a night supervisor to 
do much to help her staff in systematizing their duties 
so as to economize time. ‘There are good nurses who are 
habitually slow; faithful nurses who are always behind; 
nurses who run from one thing to another, leaving the 
first unfinished, and soon find themselves hopelessly in 
a muddle. When the clock strikes for the day nurses to 
relieve them, there are still numerous duties unfinished. 
In such cases the night supervisor has a splendid oppor- 
tunity to show the nurses how to get through, to plan a 
routine of their duties, and, by keeping them to it as far 
as possible, by making them finish up as they go along, 
lead them into better habits. 

There is one difficulty in planning the night work of a 
hospital which needs constantly to be guarded against, 
and in some cases legislated against. ‘This arises from 
the bad habit some doctors have of making evening visits 
and leaving a list of new orders for the night nurses, which 
necessitates an additional burden of work that should 
have been attended to by the day staff. Very frequently 
one night nurse must take charge of patients that are 
divided among three or four nurses during the day. If 
the work is properly planned,—dressings, baths, and 
daily treatments attended to during the day,—this can, 
as a rule, be managed without serious difficulty. But 
if an interne or a visiting physician is allowed to come 
in at 9 p.m. and order enemata for two or three patients 
that should have been ordered in the morning; if another 
doctor can come in and order a bladder irrigation for his 


NEG HoT SU BE RV ES) OLR 237 


patient; another, massage for his—the best system in the 
world will fail. The most capable nurses will find it 
absolutely impossible to give general attention to all the 
patients, answer bells promptly, and at the same time 
carry out these special orders for the few. There are 
some physicians so thoughtless, so absolutely devoid of 
system in their own work, and so utterly indifferent to 
the rights of hospital workers that they need very strict 
dealing with on the part of the superintendent if confusion 
of orders.and burdens grievous to be borne are not common 
experiences of the night staff. 

To the slow nurse who is always behind there usually 
seems to be but one remedy—to begin the regular morning 
work earlier. It is not uncommon to find night nurses 
waking up the patients at 2 o’clock to have their morning 
toilets attended to and their temperatures taken. It 
is true, the night staff is often overburdened, especially 
in the evening and early morning hours, but careful 
systematizing of the work will help wonderfully in getting 
through, and in times of extra pressure extra nurses should 
be provided for the busy morning hours. It should be 
no unimportant part of the night supervisor’s duties to 
plan the routine of work, and also to see that the patients 
are not aroused from their slumbers at such unseasonable 
hours as they often are, when the matter is left entirely 
to the pupil nurse’s judgment. 

In the matter of punctuality, the night supervisor can 
teach by example as well as by precept. Especially is 
this needed in regard to coming to meals. If the hospital 
rules require night nurses to be in the dining-room at a 
given time, it is the supervisor’s duty to see that they are 
there. If the rules say that night nurses must be in bed 


238 NIGHT SUPERVISOR 


at a certain hour, and must remain there a given time, 
she has no right to ignore irregularities and allow nurses 
to violate rules without reporting them. 

In forming habits of study, the night supervisor can do 
much by encouraging her night staff to set apart some 
regular time each day to real systematic study. It is a 
common complaint of nurses that they cannot study 
because they are on night duty. That notion needs to be 
combated, for it is true that nurses who are really am- 
bitious to study have found their term of night duty no 
drawback, but rather favorable. Much time is wasted 
by probationers and nurses in aimless gossiping. Clad 
in kimonos, they congregate in each other’s rooms and 
spend hours rehearsing the day’s events, in discussing their 
patients or the doctors, what they get to eat or what they 
think they should get, what Mrs. Fisher said or Miss 
Green did, while at the same time they groan and continue 
to groan and complain that they have no time for study. 
Not only are they wasting time and energy in giggling and 
unprofitable conversation, but they are forming habits 
of gossiping about people that will be a detriment to them 
through life. The nurse’s life in a hospital is cireum- 
scribed and narrow and depressing, which is all the more 
reason why head nurses should not only put forth extra 
efforts to discourage personal gossip, but to awaken a 
desire for higher things. 

It may seem needless to state that the same strict rules 
of discipline should prevail on night duty as on day duty; 
but it is a fact that disciplinary regulations in some hos- 
pitals are greatly relaxed at night. Sometimes a degree 
of freedom, where internes are concerned, is permitted 
that, on day duty, would not be tolerated. Sometimes 


NEGHT SUBPERVISOE 239 


nurses are allowed to visit in patients’ rooms promiscu- 
ously, and to visit each other in wards at night when the 
tules emphatically forbid. These are points on which 
the blame rests more on the head nurse than on any other 
person. It is not only her business to obey the rules of 
the institution which pertain to her, but to see that the 
nurses of whom she is in charge do not violate those that 
pertain especially to them. 

That little motto, mentioned before, “study to be quiet,” 
is one which the night supervisor needs to keep constantly 
before her staff. Many a nurse with good judgment in 
other things, good ability, good conscience, and good 
health, has made a poor record as a night nurse because 
she was noisy. Doors banged, bed-pans rattled, her 
feet came down with a thud, she talked in a loud tone, 
everything she touched seemed to make a noise, and 
every one in her department was unnecessarily disturbed. 
The most highly strung patient’s nerves were continually 
on a tension—all because the nurse had not learned to be 
quiet. The art of doing one’s work quietly comes easier 
to some than to others, but it can be, and should be, 
studied by all. No one is in better position to teach this 
art than is the head nurse. 

The night supervisor will often be sought as a confi- 
dential adviser by some pupil nurse who feels she has 
a grievance against her day head nurse. She sees what she 
thinks is favoritism shown, or she has been reprimanded, 
or misunderstood, or in some way an injustice has been 
done her. Perhaps, while smarting under a rebuke, 
she pours out her troubles to the night supervisor. It is 
a delicate situation, one requiring infinite tact, and often 
she scarce knows what to answer. There is one thing 


240 NIGHT SUPERVISOR 


that should always be kept in view in dealing with such 
situations. If real harmony is to prevail in the institu- 
tion, a sense of loyalty to each other must be shown by 
head nurses. No one should be led into doing or saying 
a thing that might weaken another head nurse’s authority, 
or detract from the respect due the position. Regardless 
of personal feelings in the matter, even though one side 
of the story seems to point toward injustice, a discreet 
silence or a non-committal attitude is the best course for 
all concerned. At the same time, a sympathetic hearing 
and wholesome counsel can always be given to the nurse 
whose feelings have been wounded. 

The nurse who craves popularity, who prizes it above 
the consciousness of duty faithfully performed, should 
never be given head-nursing responsibilities. No one 
whose business it is to correct and supervise, to enforce 
rules and point out faults, can expect to be popular in the 
ordinary acceptance of the term. Human nature is so 
constituted that it does not keenly relish having failures 
and defects in work and character or conduct brought 
under condemnation, even though it is conscious of them. 
Having favorites among nurses, the establishing of a 
gossipy attitude, confidential personal relations with sub- 
ordinates, are serious faults in a head nurse. ‘The head 
nurse who aims to be popular with her probationers and 
staff nurses is reasonably certain to fail in her duty to the 
patients and to the institution. 

Frequent conferences with the superintendent will do 
much to keep the night head nurse in touch with institu- 
tional affairs in general. A preliminary talk on the part 
of the superintendent to each new force of night nurses 
will help toward securing good work and the maintenance 


NIGHT SUPERVISOR 241 


of proper discipline. Of necessity, the life on night duty 
is somewhat isolated. The nurses come in contact with 
comparatively few people except the sick, and a depres- 
sion, partly physical, partly mental, seems inevitable 
because of the turning of day into sleeping-time and 
night into working time. Naturally, the head nurse shares 
to a degree this depression, but the experience is one that 
affords splendid opportunity of developing resourceful- 
ness and many other qualities that can never be called 
into play without the responsibility for their use that is 
necessitated by night duty. 


16 


CHAPTER XXIV 
The Chief Surgical Nurse 


The chief surgical nurse occupies a position of respon- 
sibility second only to the superintendent. On her keen- 
ness, her organizing ability, her conscientiousness in 
details will depend, to a great extent, not only the repu- 
tation of the hospital, not only good results in surgery, 
but the lives of many of its patients. In addition to the 
qualifications needed for successful head nursing in general, 
she needs to be thoroughly abreast of the times in regard 
to her own branch of nursing. 

In undertaking her work, a comprehensive system of 
procedure, thoroughly understood by pupil nurses, will 
greatly facilitate the daily routine and save much time. 
“To every man his work” is a good rule, care being taken. 
that each detail of an operation has been anticipated and 
definitely assigned. In most hospitals with an active 
surgical service the operating corps consists of the chief 
nurse and two pupils. The following method of organ- 
ization has been found thoroughly satisfactory. The 
head nurse has charge of the operating-rooms, anesthetic 
room, aseptic preparation room, emergency room, ster- 
ilizers, ete. She is responsible for the conditions of the 
instruments, must keep them catalogued, counted, and 
be ready to account for them at any time; all surgical 
material used throughout the hospital is prepared under 


her direction; she superintends and assists in the prepara- 
242 


Sneek SUR GLeA LN URS 248 


tion for the operation, and acts as second assistant; 
she is held responsible for the proper labeling of patho- 
logic specimens and must see that they reach the patho- 
logic department in good order. 

The senior pupil nurse has for her special duties the 
preparation of all unsterilized materials; she does the 
work of the “clean nurse” at operations; she is held 
responsible for counting the sponges and also replenishing 
the supplies throughout the house. In preparing for 
operations she is held responsible for the presence and 
condition of the operating clothing, the gowns, face- 
masks, and aprons of the surgeon and all his assistants, 
also for the brushes and rubber gloves. 

The junior pupil nurse does all the duties that fall to 
the lot of the unsterilized or general nurse. During opera- 
tions she supplies visitors with gowns, lifts the patient to 
and from the table, assists the assistant surgeon in pre- 
paring the field of operation, empties basins and renews 
solutions, keeps the floor clear and clean, picks up fallen 
instruments, is responsible for the operating blankets and 
arm or leg supporters, changes the patient’s gown after 
operation, and assists the anesthetist as may be necessary. 
She is responsible for the dusting of the operating-room, 
_ for cleaning rubber goods, for the tables, pillows, and 
their coverings. Prior to operations she assists in pre- 
paring dressings and the arranging of the anesthetist’s 
table is included in her duties. After operations she 
removes the blood-stains from clothing and collects it 
for the laundry. 

In the operating-room, expensive supplies are constantly 
in use and the tendency each year seems to be toward 
increase rather than decrease in the cost of the surgical 


2444 CHIEF SURGICAL NG 


department. Experience has shown that it is in the 
power of a head nurse to influence very decidedly the 
cost along certain lines. For instance, a change of operat- 
ing-room nurses in one hospital resulted in a decrease of 
almost one-half in the quantity of ligature material used, 
while the results were equally satisfactory and the physi- 
cians better satisfied. The one nurse had been trained 
to economize, the other had not. 

In the matter of absorbent gauze, great waste is possible, 
and in many hospitals waste is the rule. A system of 
washing and resterilizing gauze that has been used in 
the operating-room has been introduced into some hospi- 
tals, with the result of a saving that amounts to thousands 
of dollars in the course of a year. The method employed 
in the Massachusetts General Hospital, Boston, has been 
described by Dr. F. A. Washburn, the assistant superin- 
tendent, as follows: “All gauze and bandages from ward 
dressings, amphitheater, out-patient department, and 
operating-rooms are collected in paper bags and taken to the 
laundry. It is transferred from these paper bags to open- 
work bags made of cord, these bags being only half filled. 
The gauze is kept in these bags throughout the rest of the 
process of washing and the laundry sterilization. It is 
put in soak overnight in cold water, which is changed 
several times. The following morning it is put into an 
iron washer capable of resisting steam pressure up to ten 
pounds. It is first washed in cold water until the water 
runs perfectly clear. The gauze is then washed with warm 
water, soap, and sal soda. After the washing it is rinsed 
in hot water. After the rinsing, enough hot water is 
turned into the washer to cover the bags of gauze as they 
lie on the bottom of the washer. Steam is then turned 


x 


CHrer SUR GICAL N URISIE (245 


on to a pressure of ten pounds. A self-registering ther- 
mometer placed in the gauze twice showed a temperature 
of 239° and 240°. ‘This temperature is maintained for one- 
half hour. During all this process the washer is moving 
with a to-and-fro motion which continually agitates the 
gauze and presents all parts of it to the motion of the 
water and steam. The gauze is then put into the ex- 
tractor, and when dry is overhauled and _ straightened 
and instructions given to throw out any piece which is 
stained or has anything adherent to it. The final sterili- 
zation is then done at a temperature of 250° F., with a 
pressure of fifteen pounds in the sterilizing room. So much 
for the gauze which is recovered and utilized as gauze. 
There is a part which is in too small pieces, or is too badly 
tangled to be worth straightening. ‘This material is run 
through a rag-picker and becomes a very light and absor- 
bent lint, which is sterilized and used in dressings where 
absorbent cotton or oakum is ordinarily used. It is also 
used in the boiler house in the place of waste for wiping 
around the engines. Another part of the gauze is thrown 
out because it is stained with chemicals. ‘These pieces are 
utilized by the house-cleaning force. 'This process, there- 
fore, means not only less gauze bought, but less absorbent 
cotton, less oakum, less waste for the engine-room.” 
The demand of present-day surgeons for rubber gloves 
has added a very costly item to operating-room equipment. 
That a very considerable saving is possible along this 
line has been revealed by statistics from different hospi- 
tals. ‘The amounts used vary considerably. In one 
hospital 300 pairs were used for 162 operations; in an- 
other, twelve pairs for 252. One hospital reported that 
a considerable saving was effected by boiling for only 


2446 CHIEF SURGICAL Nae 


two minutes. In other hospitals boiling is not practised 
at all, the gloves being powdered and steam-sterilized 
in packages. Care in putting on and removing is the 
important thing in prolonging the life of a glove. Patch- 
ing the old gloves with adhesive dam and cement prolongs 
their usefulness and decreases expense. ‘These should be 
repaired after each day’s operations. 

By careful handling of the instruments and accounting 
‘for them by frequent inventories a head nurse can effect 
a very decided saving in the course of a year. Alcohol 
is another article which is apt to be lavishly used and 
wasted. Some head nurses watch this point very care- 
fully, saving all the alcohol left after pouring over hands 
or instruments for disinfection, and sending it to the wards 
to be diluted for external rubbing. 

In the cutting of dressings and preparing them for ward 
use there is abundant opportunity for the practice of 
intelligent economy. A difference of an inch in the size 
of a sponge makes a difference of many dollars a month 
in the aggregate, when much dressing material is in use. 

The ordinary cotton waste used for cleaning machinery, 
and that can be purchased for less than half the price of 
absorbent cotton, can be made thoroughly absorbent by 
’ boiling in a soda solution and makes an excellent filling 
for vulva pads. 

The management of the linen for the operating-room 
presents a serious question—one on which a great deal 
depends on the personal habits of the surgeons. In one 
hospital it was found necessary to limit the number of 
sterilized gowns that could be provided for one operation 
to five. The results were fully as good as when gowns 
were demanded for every visiting physician or student who 


CHIEF SURGICAL NURSE 247 


happened to be admitted to the operating-room. Pre- 
vious to this ruling, gowns were often demanded by the 
surgeons as an act of courtesy to their visitors, rather than 
because they were needed for the sake of asepsis. 

In the matter of sheets and towels, the nurse must also, 
to a great extent, be guided by the surgeons, but not 
entirely. If she is alert and careful, she can, by a glance, 
restrain pupil nurses who are thoughtlessly and needlessly 
opening fresh packages, or check the sending back to 
the laundry linen that is not soiled and might be resteril- 
ized. 

These are only a few of the points that need to be 
guarded. A head nurse’s ability, or the ability of any 
hospital employee, is not measured simply by her techni- 
cal knowledge. She must be able to manage her depart- 
ment efficiently and at the same time economically. A 
head nurse who can reduce the expenditure in an operating- 
room ten dollars a month as compared with her prede- 
cessor, is worth ten dollars more a month, and her value 
will undoubtedly be recognized in time. 

The cost of the supplies she constantly handles is a 
point on which the head nurse should familiarize herself 
by a study of surgical supply catalogues. No nurse who 
has the good of the institution at heart, or who has real 
pride in her management, will long be content, even 
though wilful extravagance is the rule when she assumes 
charge, to allow that state of things to continue. An 
ambition to reduce the amount of supplies, month by month, 
until the minimum amount possible with good work is 
reached has resulted in an enormous saving to some hos- 
pitals. A nurse graduate who had charge of a small 
hospital remarked to her superintendent when she returned 


248 CHIEF SURGICAL NURS 


to visit the hospital in which she had been trained: “I 
could run the operating-room in my little hospital with 
the waste from the operating-room here.’”’ What has 
been done in one hospital can be done in others toward 
reducing the cost of the surgical department. Here, as 
everywhere, the first step in good management is keeping 
account of the items every day. 

Much is said and written as to technic. But chief 
operating-room nurses, as a rule, fail less frequently in 
matters of technic than along other lines in their manage- 
ment of an operating-room, though they do fail in technic 
sometimes. One nurse who appeared to be “diligent in 
business,” proved a failure from lack of methodic planning 
for an operation. She depended too much on her assist- 
ants running hither and thither to hand things while an 
operation was in progress. When a catgut ligature was 
called for, it was on a table in a remote corner and she 
had to wait for an assistant to get it. If she needed a 
strip of iodoform gauze, it was in a jar somewhere else. 
Her hands being sterile, she must have an assistant to 
help her to get it. The assistant was meanwhile busy 
emptying basins, getting hot water, etc., and the result 
was a constant delay and confusion irritating to the sur- 
~ geon and to all concerned. She lacked in readiness, and 
her service was unsatisfactory. 

Another common failure is that the chief surgical nurse 
becomes too intimate with the nurses in training in her 
department. Their relations become so familiar that 
discipline is out of the question. Laxity in work is pretty 
sure to result when this occurs. A chief nurse who allows 
the orderly to loiter around and visit with her nurses while 
they are preparing dressings; who allows the medical 


} 


CHIEF SURGICAL NURSE 249 


students to become so well acquainted with them that a 
freedom bordering on familiarity results, or who herself 
establishes familiar relations with them, thereby demon- 
strates her unfitness for the position. Womanly dignity 
is a primary requirement for such work unless the whole 
tone of the operating-room is to be undignified, inferior, 
and cheap, free, and easy. 

The inability to observe all the needs of an operating- 
room while an operation is in progress, or to plan for 
succeeding operations so that no time is lost, is another 
common cause of failure. Some of the qualifications for 
successful generalship are certainly necessary on clinic 
days, or any day when several operations are to take place 
in quick succession. It is not alone what she herself 
does, but how she manages her whole force of assistants 
so that valuable time is not lost, that determines real suc- 
cess in management in this direction. 

Just how much teaching the head nurse in the operating- 
room should do depends somewhat on circumstances and 
on how much teaching the pupil nurses have had along 
surgical lines before coming to the operating-room. How 
much she will do depends on herself, on her ability to 
give instruction, on her appreciation of her responsibility 
toward the pupil nurses assigned to her department. 
The opportunity for efficient teaching is in every operat- 
ing-room. Illustrations of conditions, theories, and facts 
are easily found. 

It does not require a stated hour and class-room para- 
phernalia in order to teach a valuable lesson in surgical 
practice. Much of the theory previously acquired along 
surgical lines ought to be reviewed and demonstrated 
while in the operating-room. The cleaning-up process 


250 CHIEF SURGICA LI NU 


need be none the less thorough if the chief nurse takes 
occasion to question and explain regarding the various 
points about the operation that has just taken place, if 
there is no other operation to follow immediately. The 
preparation for an odphorectomy for ovarian cyst, for 
example, need be none the less thorough and complete 
if the chief nurse uses the occasion to state in detail to 
her assistants the different steps in the operation,—the 
preparation of the field, the incision, the emptying of the 
cyst, drawing of the sac out of the abdomen, separation 
of adhesions, ligation of the pedicle and blood-vessels, 
excision of the cyst, cleansing of the abdomen by sponging 
or flushing, closure of the wound,—the instruments and 
appliances required for the different steps of the process, 
and the nurse’s duty at each stage. Under such instruc- 
tion the pupil nurses should come out of the operating- 
room with an intelligent idea of the work in all its details. 

In no line of nursing is more good literature available 
than in the line of surgical nursing and operating-room 
work. And yet, there are many pupil nurses who come 
out of our operating-rooms after a three or four months’ 
term who have been drilled in the mechanic work, taught 
to carry out a certain routine of duties in a mechanic 
' way, but who have utterly failed té grasp the fundamental 
principles on which modern surgery is based, or to have 
any clear idea of methodic planning for such work else- 
where. ‘They are careful about their work, or mean to 
be, but they are not intelligently careful, and when they 
have the entire responsibility of preparing for and assist- 
ing at an operation, they make breaks in technic which 
are absolutely inexcusable in these days of intelligence 
and exactness along surgical lines. For instance, a nurse 


CT EH (SU R Gil eC AEs NURS Ey 250 


graduate of one of our large eastern hospitals, in preparing 
for an operation in a private home, boiled the water in 
a wash-boiler, but failed to provide anything but an un- 
sterilized dipper to dip it out. Another nurse, after her 
term in the operating-room, did not know what was meant 
by the terms “ligature” and “suture,’’ and could not 
write a list of the instruments required for even the sim- 
plest operation; could not state definitely how long would 
be required to sterilize any of the small instruments and 
appliances used every day in her work. There is a good 
deal that goes into some courses of lectures on surgical 


work in our training-schools that it would not make much , 


difference if a nurse did not know. She can do good work 


if she does not know the difference between a greenstick | 


and an epiphyseal fracture, if she does not know the 
history of the discovery of anesthetics, or a dozen other 
things which modern lecturers think “‘it is nice for a nurse 
to know.” But if, after three months in an operating- 


room, she is not able to state intelligently how infection in | 
a wound may take place, how organisms may get into a | 
wound; if she cannot quickly place a patient in the dif- | 
ferent positions required for various treatments; if she | 
does not know what instruments are likely to be required | 


for an operation for appendicitis, then there has certainly 


been a grave deficiency in her training for which some one / 


is responsible. 

An operating-room nurse can afford to get on without 
some books on nursing which nurses in general practice 
should own, but she ought to be sufficiently ambitious 
in her own line to buy the latest and best books on operat- 
ing-room technic that are available. This is an age 
of specialization along all lines. Hospital work needs 


252 CHIEF SURGLCALT NG 


specialists among nurses quite as much as among 
physicians, while there will always be a demand for the 
all-round woman. Each year thousands of nurses are 
graduated. It ought not to be difficult for a hospital to 
secure a good operating-room nurse, or a good efficient 
head of an obstetric department—one who can not only 
manage her department, but can teach her specialty and 
put her own stamp on her nurses, but it is often difficult. 
Good head nurses are not readily found because so few 
nurses, comparatively, are willing to pay the price of 
efficiency along those lines, to dig, and study, and take 
time to thoroughly master the line of work they want to 
do; so few nurses, comparatively, who are real students 
throughout their entire professional lives. 


CHAPTER XXV 
The Head Nurse and Case Histories 


What has a head nurse or any nurse to do with the 
writing of case histories, is a question that may properly 
be asked. ‘Technically considered, such work belongs 
to the physician. The greater part of such work is done 
by physicians, and yet it is true that in some hospitals 
case histories will not be secured at all unless the head 
nurse secures them. In a considerable number of hos- 
pitals there are no internes; there is no one in the hospital 
available for such duties except the superintendent and 
head nurse. So, while some may criticize and say that 
case histories are things entirely out of a nurse’s sphere, 
yet, as a matter of fact, in some places the dividing-line 
between a physician’s province and a nurse’s province 
is made of elastic. It can be and is stretched considerably 
when there is need. Physicians of today are requiring 
nurses to do a great many things that ten years ago were 
considered entirely in the doctor’s sphere. A great many 
physicians are ready to trust an experienced head nurse 
with responsibilities which they would hesitate to trust 
to the young medical graduate or even to experienced 
practitioners who were unacquainted with their methods. 
Two points on which all medical men and well-trained 
nurses agree are that a nurse must not diagnose and must 
not prescribe. They agree that it is the business of the 
nurse to be an assistant and ally of the physician in his 

253 


254 CASE HiST ORME 


endeavor to alleviate human ills. They agree, further, 
that she ought to study to be as efficient an assistant as 
possible. Whether her assistance shall be rendered in 
bedside observation and care, in the office or the operat- _ 
ing-room, in investigation of the home conditions of his 
patient as they bear on the disease, or instructing the 
patient how to promote his own restoration to health; 
whether she shall undertake to secure for the physician 
certain facts that will assist him in diagnosis, depends 
entirely on circumstances and on the desire of the physician. 
Admitting, then, that the writing of case histories is a 
responsibility that is frequently committed to the head 
nurse, how shall she go about it? The term “case history” 
has different meanings to different physicians. The kind 
of case history she will be required to prepare will depend 
very largely on how thorough are the habits of the physi- 
cian or the hospital in this respect. Some physicians have 
very systematic habits, and require a careful history of 
every individual case of any importance which they treat, 
and the same is true of institutions. Others claim to 
keep case histories, but the physician in the former class 
would regard them as practically valueless. ‘They are 
too superficial, or too carelessly prepared to be of any real 
use to him. When the time comes that a physician needs 
to refer to a certain history to illustrate a point, or to help 
in arriving at a decision, he usually finds that, in the 
superficial, carelessly prepared histories, the very point 
he wanted has not been made a matter of record, and for 
his purpose the history has no value. In a great many 
hospitals, after twenty years of work, physicians have 
declared that no case records of any scientific value had 
been produced. In others the method of classification 


CASE HISTORIES 255 


and filing is so haphazard that the facts which have been 
secured are not accessible. 

As the head nurse writes case histories, she will learn 
to write them, and in no other way. Skill in this line 
can never be acquired by the study of books. At the same 
time she can gain from the study of symptoms and from 
the methods of physicians and institutions much that 
will help her in preparing a case history that will contain 
the important facts about the patients with whom she will 
deal. Her work will, of course, have to be directed and 
supplemented by the physician in charge. 

It is no part of her business to make a physical examina- 
tion, to state exactly what operation was done, nor the 
pathologic condition found. The history for which a 
nurse may properly be responsible will be practically 
restricted to what she can see and what she can find out 
by questioning the patient. 

A good many hospitals have history blanks prepared on 
which is printed an outline of the facts to be secured, with 
blank spaces left to be filled in. A very common mistake 
made by amateurs is in thinking that each blank space 
must be filled with something, whether the point has any 
bearing on the case or not. For instance, in taking the 
history of a patient admitted for a minor gynecologic 
operation, a young medical graduate in following the out- 
line stated that the facial expression was “pleasant.” 
It is, of course, interesting to know that any person about 
to undergo an operation is able to look “pleasant,” but it 
was hardly necessary to state the fact under the circum- 
stances. Not long since a superintendent questioned an 
interne as to whether or not he was keeping a history of 
every case admitted to his division. He replied that he 


256 CAS E Hl s\T ORME 


had not kept a history of every case. “In fact,” said he, 
“a whole lot of this history-taking is absurd. Where is 
the sense of asking a man who comes in with his head 
cut, or his leg broken, whether his grandmother had the 
measles, what his grandfather died of, how many brothers 
and sisters he had, and how old they were when they cut their 
teeth?” This interne made the mistake of thinking that 
because certain facts were of value in some cases, they were 
necessary to be secured every time. ‘The family history 
of the man with the wounded head or the broken bone 
might in most cases be properly omitted, but an accurate 
history of the present condition, the location and general 
characteristics of the wound, the condition of the patient 
on entrance, and various other facts concerning him 
should certainly form a part of the institutional records. 

Before beginning to prepare a case history it is well to 
secure from the office the facts recorded in the admission 
form and avoid repeating these questions. 

The admission blank will have spaces to record the 
name, address, occupation, place of employment, age, 
sex, race, nativity, social condition, whether married, 
single, widowed, religion, address of friends, name of 
physician who referred him, provisional diagnosis of 
examining physician, the date and hour of admission. 

The family history is important in most cases. Ex- 
perience will soon teach when it may be omitted as having 
no bearing on present conditions. The facts concerning 
the family history that are usually made a matter of 
record are: the number of brothers and sisters; whether 
they are living or dead; the general health of living rela- 
tives; causes of death; ages of father and mother; char- 
acter of serious illness occurring in the life of either; 


CASE HISTORIES 257 


possible tendency to any particular form of disease, such 
as tuberculosis, alcoholism, nervous affections, rheu- 
matism, or cancer. 

The previous history of the average patient would 
include past habits and occupations, diseases of childhood 
and of adult life, injuries, previous attacks similar to the 
present, loss or gain in ‘weight, dates, complications or 
sequels of past illness. 

The character of the provisional diagnosis will deter- 
mine the extent to which further inquiry along these lines 
should go. For instance, if the patient is a female and 
gynecologic disease is suspected, the history should state 
when the first menstruation occurred, whether menses 
are profuse or scanty, the duration, whether regular or 
irregular, painful, whether troubled with leukorrhea or 
other discharge. If the patient is married, the history 
should state at what age marriage took place; number 
of births, if any; if miscarriages have occurred; at what 
time during pregnancy; suspected or probable cause; 
number of miscarriages; whether functions were normal 
during pregnancy; general health while pregnant; char- 
acter of labors—easy or difficult; short or prolonged; 
complications or diseases occurring during pregnancy; 
general condition during puerperium and also during 
lactation; time after birth at which menstrual flow re- 
turned; if babies died, at what age and from what cause. 

The history of the present condition would include 
the chief complaint; condition preceding the attack; 
the mode of onset, whether sudden or gradual; location 
and character of pain, if any, whether sharp, throbbing, 
dull, or continuous; effect on other organs; possible 


predisposing causes; possible exciting causes; general 
17 


258 CASE HIST ORs 


disorder of functions; physical defects, if any; general 
condition as regards nutrition; facial expression, whether 
pale, haggard, anxious, dull, listless, vacant, flushed, 
or excited; temperature, pulse, and respiration; char- 
acter of discharges. 

The condition of the skin is in many cases quite import- 
ant to be noted—whether it is moist, dry, or rough, flabby, 
or wrinkled, firm, pink, and clear, jaundiced, sallow, 
bruised, or discolored; whether patches, scars, spots, or 
eruptions are present; whether shiny, waxy, or cyanotic; 
whether swelling or edema is seen. Any deviation from 
the normal structure of the body should also be noted, 
such as deformities or protrusions, asymmetry, lack of 
development, or apparent wasting of muscular tissue. 

The progress and plan of treatment of all cases should 
be made a matter of record if these histories are to have 
any real value. The bedside records kept by nurses are 
important to be made from hour to hour if exactness in 
nursing is to be secured, but there is no need of filing 
away all these details about a case. There is nothing 
to be gained by piling up these bulky documents, unless 
in exceptional cases—such as serious accident cases. It 
is important that Peter Smith should get his baths 
periodically, that he have his temperature taken at in- 
tervals, that he sit up and le down at proper times and 
seasons, that he have a cathartic occasionally, that he 
have proper meals served at the right time, but the 
great mass of these facts have no scientific value. After 
a certain time they are only so much useless lumber. It 
is important, however, that the head nurse or interne 
or whoever is responsible for case histories go carefully 
over these records and collect from them the facts which 


CAS EO EST OR BES 259 


have a real bearing on the progress and outcome of the 
case, and record it in the general history form. The 
temperature-charts of all cases should be added to this 
history. 

If this is done regularly and promptly at the conclusion 
of each patient’s stay in the hospital, when the case is 
fresh in mind, it will not entail much labor, and it will be 
found that facts that are of real scientific value in most 
cases can be recorded and filed in comparatively small 
space. 

The case history of surgical patients should contain, 
besides the facts alluded to, an accurate record of the 
operation. This operating-room history should state at 
least the pathologie condition found, and exactly what 
was done, the ligature and suture material and anes- 
thetic used, any complications that may have occurred, 
and the patient’s condition at the close of the operation. 

The value of this operating-room history is never more 
in evidence than when a laparotomy patient presents 
herself again for treatment complaining of pain or dis- 
comfort in the abdomen. With an accurate history 
telling exactly what was done it is much easier for a phy- 
sician to arrive at the cause of the present trouble and often 
exceedingly difficult without it. The patient may give 
most misleading statements as to what previous treatment 
she had, and the most skilled physician may be led to 
a wrong conclusion. It might be expected that surgeons 
would all keep their own case records. A great many of 
them do, but experience has shown that a great many do 
not. In any case, a hospital needs its own records, and 
there are many circumstances in which head nurses can do 


260 CASE HIST ORE 


much to help in making those histories complete and 
valuable. 

In obstetric work, perhaps the widest difference in the 
case histories kept by physicians and institutions will be 
found. The appended form for the histories of obstetric 
patients is the form in use in Columbia Hospital, Pitts- 
burg, and calls for a more exhaustive record than is com- 
monly kept, especially in general hospitals. No head 
nurse should pretend to be entirely responsible for an 
exhaustive history of this character. It is inserted here 
simply as affording abundant suggestion from which a 
simpler history form may be prepared, should such neces- 
sity ever arise in a nurse’s experience. 

Never before in the history of hospitals has so much 
emphasis been placed on the study of symptoms as an 
important part of a nurse’s work, not only while in train- 
ing, but throughout her nursing experience. Never has so 
much and such thorough instruction on the subject been 
given in classes and current literature as during the past 
year or two. The nurse who has availed herself of these 
opportunities and has acquired concise, systematic, and 
clear methods of expression should certainly be .able to 
prepare a case history which, so far as she has a right to 
assume responsibility for it, will contain the essential 
facts—the things that will prove of real value. 


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bowels; urine; diseases; etc. etc. 


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Internal Os: Mouth: 


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(a) Size: 
(b) Position: 
(c) Fundus: Paralyses: 


Injuries: 


Parametrium: 


Exudate: 


REFMARKS 


CASE HES PHORLES 261 


MEDICAL DEPARTMENT 


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|. FAMILY HISTORY 


Gout, Rheumatism, Syphilis, Tuberculosis, 
Alcoholism, Nervous Affections, Cancer and 
Family Deaths 


ll. PREVIOUS HISTORY 


Habits, Occupation, Diseases of Childhood, 
Venereal History, Rheumatism, Gout, Tuberculo- 
sis, Malaria, Typhoid, etc.; Previous Similar 
Attacks, Change in Weight, Previous Injury 
(Dates), Complications and Sequels. 


ill. PRESENT ILLNESS 


Onset and Chief Complaint, Nervous Symptoms, 

entary Symptoms, Abdominal Symptoms, 

Respiratory Symptoms, Cardiac Symptoms, Skin, 
Joints, Muscles, Genital Organs, Kidneys. 


IV. PRESENT CONDITION 


1. General Condition, Development, Nutrition, 
Weight. 

2. Condition of Skin. 

(a) Complexion, Anemia, Hyperemia, Cyanosis, 
Icterus, Pigmentation. 

(6) Degree of Moisture. 

(c) Degree of Surface Heat, Local or General. 

(d) Edema. 

(e) Emphysema. , 

(/) Subcutaneous Hemorrhage. 

(g) Collateral Circulation. 

eS Trophic Disturbances. 

tion of Chest. 

és) Shape; General Type. 

(6) Frequency and Rhythm of Respiratory 
Movement. 

(cq) Excursion —Degree, Symmetry. 

(d) Palpation, Percussion and Auscultation of 
oe. and Lungs. 

Examination of Pulse as to Frequency, 
Rhythm, Strength, Compressibility, and Condition 
* of Arterial Walls. 

5. Inspection, Palpation, and Percussion of Ab- 
domen. 

6. Exhaustive Examination of Diseased Part or 
Location. 

7. Examination of (in Se Cases) Eye, Mouth, 
Pharynx, Larynx, Nose, Stomach, Nervous 
System, Rectum, Vagina, etc. 


Observe tho following outline In writing the history and recording the results of the examination of the patient. 
Number according to this outline, 


262 CASE HIS TO kee 


SURGICAL DEPARTMENT 


Name, Date of admission, 190 
Sex, Age, Nationality, Race, 
Occupation, Residence, 

Sent by ; Religion, 


Name and address of friends 
Surgeon in Charge, Assistant, 


Resident Surgeon, 


History, 


Condition on admission 


Diagnosis, 


CASE? Hob Sih ORES 263 
OPERATION 
Nature, Date, 190 
First assistant, Second assistant, 
Anesthetist, 


Preparation of patient, 


Condition prior to operation, 


Anesthetic, 


Pathologic condition found, 


Mechanics of operation, 


Duration of operation, 


Ligature and suture materials, 
SPECIMENS: (a) for preservation, 
(6) for microscopic examination, 


(c) for bacteriologic examination, 


Complications during operation, 


Condition-at close of operation, 


264 CASE HiI8 TO Rite 


PROGRESS AND AFTER-TREATMENT 


Condition when dismissed, 


Result, Date of discharge, 


190 


Index 


=—=—= 


ANATOMY, how much, 9o 
specimen examination papers, 
167 
study of, 93 
teachers of, 95 
text-books, 95 
Answers, 52 
Appointments, keeping of, 159 


BACTERIOLOGY, how much, 137 

specimen examination papers, 
166 

teaching, 139 

Baths, 112 

Bedmaking, 102 

Blanks, history, 261 

Body, systems of, 92 


CANDIDATES, supply of, 33 
character of, 31 
Case histories, head nurse and, 253 
Coéperation of hospitals, 13 
Course of study, 15 
executive, 30 
teading, 34 
Courses, elective and post-gradu- 
ate, 28 
Curriculum, 20 


DEMONSTRATIONS, clinical, 100 
Dietetics, first-year studies, 81 
second-year studies, 83 
extremes, 84 
practical teaching, 89 
specimen examination papers, 
164 
Diet-sheets, 213, 221, 223 
Discipline, 194 


Douche, vaginal, 151 

Dressings, preparation of, 244 

Drugs, handling of, 218 
prescribing, 136 

Duties, future, 12 


ENEMATA, 107 
Ethics, teaching of, 196 
Examination papers, 164 
Examinations, 51 

rules of, 53 

specimen papers, 164 
Exercise, gymnastic, 206 


Foops, classification of, 75 
complete, 79 


GYNECOLOGICAL operations, 153 
Gynecology, 149 
specimen examination papers 
in, 172 


Histories, blanks, 261 
case, 253 
family, 255 
filing of, 258 
gynecological, 257 
mistakes in, 255 
preparation of, 254 
present, 257 
Honesty, 197 
Hospital ethics, 194 
Housekeeping ward, 215 
Hypnotics, 131 
effects of, 132 


INSPECTION of wards, 216 
Instruction, methods of, 42 


265 


266 


INDEX 


LECTURES, special, 19 
system, 50 


MATERIA medica: 
lectures in, 128 
specimen examination papers 
in, 168 
teachers of, 127 
teaching of, 126 
Medicine, administration of, 110 
and food, 134 


NIGHT supervisor, 234 
Nurses, head, 181 
male, 18 
night, 238 
personality of, 199 
surgical, 242 
Nursing defined, rr 
essentials of, 11 
private, 158 
specimen examination papers, 
165 
visiting, 161 


OBEDIENCE, 198 
Obstetrics, 142 
experience in, 146 
methods of, 148 
specimen examination papers, 
in, 175 
Operating-room, 242 
economy, 244 
linen, 247 
nurses, 242 
organization of, 242 
supplies, cost of, 243 
technic, 248 
Orders, reading of; 204 
writing of, 225 


PAPERS, preparation of, 55 
specimen examination, 164 
Patients and nurses, 188 
reception of, 186 
religious beliefs, 190 
Patient’s friends, 189 


Penalties, 202 
Pharmacology, 71 
Physicians, lectures, 48 
as teachers, 94, 138 
methods, 96 
mistakes in teaching, 138 
theories, 95 
Physiology, specimen examination 
papers, 167 
teaching of, 90 
Position of patients, 152 
Principles, fundamental, 57 
Private nursing requirements, 155 
instruction, 157 
teachers of, 156 
Probationers, practical work for, 
39 
rejection of, 159 
Punctuality, teaching of, 237 
Pupils, character of, 31 
coéperation of, 46 
high school, 32 


QUESTIONING, 48 
Questions, specimen, 164 
Quietness, 209 

teaching of, 239 


RECITATIONS, 47 

Records, bedside, 228 

Recreation hours, 219 

Remedies, 63 
imponderable, 65 
mechanical, 67 
miscellaneous, 68 

Reports, 224 

Rooms, care of, 105 


SANITATION, 103 
Study, habits of, 238 
Supervision, night, 234 
Supervisors, relation of, 235 
Surgical nurse, chief, 242 

technic, teaching of, 137 
Symptoms, 116 

observing, 117 

clinical course, 117 


INDEX 267 


TEACHING, 44 UTERUS, cancer of, 150 

art of, 41 

ene hiram Puaaai qualifications 
Technic, surgical, 142 er aes 
Text-books, 28 
Therapeutics, 72 Warp housekeeping and manage- 
Training, preliminary, 36 ment, 211 
Trays, 212 Waste, prevention of, 244 


Treatment, principles of, 59 Water, 79 


) 
( 
‘ 
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SAUNDERS’ BOOKS 


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Aikens’ Clinical Studies for Nurses 

Aikens’ Primary Studies for Nurses. . 

Aikens’ Training School Methods and the edd Nurse . 
Beck’s Reference Handbook for Nurses 

Davis’ Obstetric and Gynecologic Nursing 
DeLee’s Obstetrics for Nurses : 

Dorland’s American Illustrated Medical Dictionary. 
Dorland’s American Pocket Medical Dictionary . 
Fkowler’s Operating Room and Patient 
Friedenwald and Ruhrah on Diet 

Grafstrom’s Mechanotherapy (Massage) 

Griffith’s Care of the Baby. 

Hoxie’s Medicine for Nurses . fee 
Lewis’ Anatomy and Physiology for Wires a 
Macfarlane’s Gynecology for Nurses. . 
McCombs’ Diseases of Children for Nurses . 
Morris’ Essentials of Materia Medica . ; 
Morrow’s Immediate Care of the Injured... . 
Nancrede’s Essentials of Anatomy . 

Paul’s Materia Medica for Nurses. . . as 
Paul’s Nursing in the Acute Infectious Weyer - 
Pyle’s Personal Hygiene 

Register’s Fever Nursing 

Stoney’s Bacteriology and Surgical Technic . 
Stoney’s Materia Medica for Nurses . 

Stoney’s Nursing . 

Wilson’s Reference Eartha of Obstetric acer 


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32mo volume of 200 pages. Bound in flexible leather, $z.25 net. 


Paul’s Materia Medica 


The physiologic actions Dr. Paul arranges according to the 
action of the drug and not the organ acted upon. JVurses 
Journal of the Pacific Coast says: ‘‘ The arrangement is most 
admirable. One of the features is the text on pretoxic signs.”’ 


A Text-Book of Materia Medica for Nurses. By GEORGE P. PAUL, 
M. D., Assistant Visiting Physician and Adjunct Radiographer to the 
Samaritan Hospital, Troy, N. Y. 12mo of 240 pages. Cloth, $1:50 net. 


DeLee’s Obstetrics for Nurses = enmon 


Dr. DelLee’s book really considers two subjects—obstetrics 
for nurses and actual obstetric nursing. TZ vained Nurse and 
Flospital Review says the ‘‘book abounds with practical 
suggestions, and they are given with such clearness that 
they cannot fail to leave their impress.’’ 


Obstetrics for Nurses. By JOSEPH B. DELEE, M. D., Professor of 
Obstetrics at the Northwestern University Medical School, Chicago. 
rzmo volume of 512 pages, fully illustrated. Cloth, $2.50 net. 


Davis’ Obstetric & Gynecologic Nursing 
THE NEW (3d) EDITION 


The Trained Nurse and Hospital Review says: ‘‘ This is one 
of the most practical and useful books ever presented to the 
nursing profession.’’ The text is illustrated. 


Obstetric and Gynecologic Nursing. By EDWARD P. Davis, M. D., 
Professor of Obstetrics in the Jefferson Medical College, Philadel- 
phia. xzmo volume of 436 pages, illustrated. Buckram, $1.75 net. 


Macfarlane’s Gynecology for Nurses 


RECENTLY ISSUED 
Dr. A. M. Seabrook, Woman’s Hospital of Philadelphia, says: 
“Tt is a most admirable little book, covering in a concise but 
attractive way the subject from the nurse’s standpoint. You 
certainly keep up to date in all these matters, and are to be 
complimented upon your progress and enterprise.’’ 


A Reference Handbook of Gynecology for Nurses. By CATHARINE 
MACFARLANE, M. D., Gynecologist to the Woman’s Hospital of Phil- 
adelphia. 32mo of 150 pages, with 70 illustrations. Flexible leather, 
$1.25 net. 


Paul’s Fever Nursing 


Nursing in the Acute Infectious Fevers. By GrOROE 
P. Paut, M. D., Assistant Visiting Physician and 
Adjunct Radiographer to the Samaritan Hospital, Troy. 
12mo of 200 pages. Cloth, $1.00 net. 


5 


Friedenwald and Ruhrah’s Dietetics 
for Nurses JUST ISSUED—NEW (2d) EDITION 


This work has been prepared to meet the needs of the nurse, 
both in the training school and after graduation. It aims to 
give the essentials of dietetics, considering briefly the physi- 
ology of digestion and the various classes of foods. American 
Journal of Nursing says it ‘‘is exactly the book for which 
nurses and others have long and vainly sought. A simple 
manual of dietetics, which does not turn into a cook-book at 
the end of the first or second chapter.’’ 

Dietetics for Nurses. | By JULIUS FRIEDENWALD, M. D., Professor 

of Diseases of the Stomach and JOHN RUHRAH, M. D., Professor of 


Diseases of Children, College of Physicians and Surgeons, Balto- 
more. 12mo volume of 395 pages. Cloth, $z.50 net, 


RECENTLY ISSUED 


American Pocket Dictionary New em evrrion 


This is the ideal pocket lexicon. It contains a complete vo- 
cabulary, defining a// the terms of modern medicine. The 
Trained Nurse and Hospital Review says: ‘‘ We have had 
many occasions to refer to this dictionary, and in every in- 
stance we have found the desired information.’? The work 
also contains a wealth of anatomic tables of value to nurses. 


Dorland’s Pocket Medical Dictionary. Edited by W. A. NEWMAN 
DORLAND, M. D., of the University of Pennsylvania. rlexible 
leather, with gold edges, $1.00 net; with patent thumb index, $1.25 net. 


NEW 


Grafstrom’s Mechano-therapy gz epmon 
The Boston Medical and Surgical Journal says: ‘‘ It states in 
concise language the various methods which by long experience 
have been found useful in treament by mechanical means.”’ 


Mechano-Therapy (Massage and Medical Gymnastics). By AXEL V. 
GRAFSTROM, B. Sc., M. D., Attending Physician, Gustavus Adolphus 
Orphanage, Jamestown, N. Y. x12mo, 200 pages. Cloth, $1.25 net. 


Friedenwald & Ruhrah on Diet sive chron 


Diet in Health and Disease. By Julius FRIEDENWALD, 
M.D., Professor of Diseases of the Stomach, and JoHN 
RuHRAH, M.D., Professor of Diseases of Children, 
College of Physicians and Surgeons, Baltimore. Octayvo 
volume of 764 pages. Cloth, $4.00 net. 


‘ 


6 


McCombs’ Diseases of Children for Nurses 


Dr. McCombs’ experience in lecturing to nurses has enabled 
him to emphasize just those points that nurses most need to know. 
National Hospital Record says: ‘‘We have needed a good 
book on children’s diseases and this volume admirably fills 
the want.’’ The nurse’s side has been written by head 
nurses, very valuable being the work of Miss Jennie Manly. 


Diseases of Children for Nurses. By ROBERT S. McComes, M. D., 
Instructor of Nurses at the Children’s Hospital of Philadelphia. 12mo 
of 431 pages, illustrated. Cloth, $2.00 net 


Wilson’s Obstetric Nursing 


In Dr. Wilson’s work the entire subject is covered from the 
beginning of pregnancy, its course, signs, labor, its actual 
accomplishment, the puerperium and care of the infant. 
American Journal of Obstetrics says: ‘‘ Kvery page empasizes 
the nurse’s relation to the case.’’ 


A Reference Handbook of Obstetric Nursing. By W. REYNOLDS 
WILSON, M.D., Visiting Physician to the Philadelphia Lying-in Char- 
ity. 3zmo of 355 pages, illustrated. Flexible leather, $1.25 net. 


Morris’ Materia Medica sana toad BREIOR 


The Zvained Nurse and Hospital Review says: ‘‘The work is 
thoroughly up to date, well arranged, compact, and yet con- 
tains a very large amount of matter.’’ 

By HENRY Monts, M.D. Revicsl by WA. Bagieue, Me be 


Instructor in Materia Medica and Pharmacology at the Colum- 
bia University, New York. xz2mo of 300 pages. Cloth; $1.00 net, 


Griffith’s Care of the Baby NEW (4th) EDITION 


The New York Medical Journal says: ‘‘ We are confident if 
this little work could find its way into the hands of every 
trained nurse, infant mortality would be lessened by at least 


fifty per cent.’’ 
The Care of the Baby. By J. P. CROZER GRIFFITH, M. D., Clinical 
Professor of Diseases of Children, University of Pennsylvania 
12mo Of 455 pages, illustrated, including 5 plates. Cloth, $1.50 net. 


7 


Lewis’ Anatomy and Physiology 


The Nurses Journal of the Pacific Coast says ‘‘it is not in any 
sense rudimentary, but comprehensive in its treatment of the 
subjects in hand.”’ 


Anatomy and Physiology for Nurses. By LEROy LEwIs, M.D., Lec- 
turer on Anatomy and Physiology for Nurses, Lewis Hospital, Bay 
City, Mich. 12mo of 347 pages, 146 illustrations. Cloth, $r.75 net. 


Dorland’s Illustrated Dictionary 
JUST READY—THE NEW (5th) EDITION—2000 NEW TERMS 
Vhis edition contains over 2000 new terms. Dr. Howard A. 
Kelly says: ‘‘ Dr. Dorland’s Dictionary is admirable. It is so 
well gotten up and of such convenient size. No errors have 
been found in my use of it.’’ 
qenng used In Medicine, Surgery, Dentiguys Pharmacy. Chante 
and kindred branches; with roo new and elaborate tables By W. 


A. N. DORLAND, M. D. Large octavo of 898 pages, 293 illustrations, 
11g in colors. Flexible leather, 54.50 net: thumb index, Ss.0co net 


Morrow’s Immediate Care of Injured 


The Trained Nurse and Hospital Review says: ‘‘ We are most 
pleased with the work. The illustrations are clear and prac- 
tical; the wording plain and reasonably concise.’’ It is an 
invaluable work for the nurse—practical in the extreme. 


Immediate Care of the Injured. By ALBERT S. MorRROw, M. D., 
Attending Surgeon to the New York City Home for the Aged and 
Infirm. Octavo of 340 pages, with 238 illustrations. Cloth, $2.50 net. 


Register’s Fever Nursin 
g g 


A Text-Book on Practical Fever Nursing. By Epwarp 
C. REGISTER, M.D., Professor of the Practice of Medi- 
cine in the North Carolina Medical College. Octavo 
of 350 pages, illustrated. Cloth, $2.50 net. 


Pyle’s Personal Hygiene NEW (3d) EDITION 


A Manual of Personal Hygiene. Edited by WaLTER 
L. Pye, M.D., Wills Eye Hospital, Philadelphia. 
Octavo, 451 pages, Illustrated. $1.50 net. 


8 


